SP - Other medical conditions

BACKGROUND:

At Sheffield Teaching Hospitals, an Older Surgical Patients Pathway (OSPP) began in 2014, introducing a Consultant Geriatrician working in a liaison role within General Surgery.

BGS reports in its 'Case for more Geriatricians' that the number of people aged over 85 is set to double by 2045. An increase in patient age and complexity is already being seen across a range of services including admissions to general surgery.
We look to characterise this increase to make the case for an expansion of the OSPP service.

METHODS:

1. We identified patients aged over 75 admitted under General Surgery in July to December of 2014 and 2023.

2. We analysed these patients for their 30 day mortality, theatre episodes, length of stay and Hospital Frailty Risk Score (an automatic calculation from hospital records using a weighted count of frailty- related diagnoses).

RESULTS:

The number patients aged over 75 admitted in the 6 months from July to December has increased from 646 in 2014 to 847 in 2023.

The increase in this age group is associated with an increase in the number of patients with a hospital frailty score greater than 20 (from 18 to 69) and those with a length of stay longer than 15 days (from 93 to 124).

Additionally, between 2014 and 2023 patients aged over 75 had an increase in total theatre episodes (from 107 to 125) and 30 day mortality (from 48 to 63).

We propose that this increase in number and complexity of older patients supports the expansion of OSPP Service, for example by the addition of a ST3+ level doctor.

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.     

Introduction: Older adults are the fastest growing and most sedentary group in society. With sedentary behaviour associated with negative health outcomes, reducing sedentary time may improve overall wellbeing. This single-arm mixed-method feasibility study explored the acceptability of an intervention to reduce sedentary behaviour in community-dwelling older adults aged ≥75 years.

Methods: Participants were recruited from the Community Ageing Research 75+ Study (CARE75+) cohort, with factors such as age, frailty status, living arrangements and levels of sedentariness being considered. The intervention consisted of an educational booklet including advice on how to reduce sedentary behaviour, a smartwatch with a sedentary reminder function, educational group sessions and follow up phone calls. The 9-week intervention was conducted from June-August 2023. Reach, uptake, adherence, and adverse events were recorded, and the acceptability of the intervention was explored through semi-structured exit interviews.

Results: Of the 39 eligible participants, 10 consented (5M:5F) and had a mean age 84.3 years. The intervention had an uptake and reach of 25.6%, and retention of 100%. No falls, hospitalisations or deaths occurred, and three cases of mild irritation were reported which resolved during the study. 100% adherence was observed for the group sessions and follow-up phone calls, and 65% for self-monitoring. Qualitative data suggests that participants were receptive of the intervention according to the domains of the Theoretical Framework of Acceptability, and suggestions were provided on refining the intervention components.

Conclusion: Strategies to reduce sedentary behaviour were tested on a diverse sample of community-dwelling older adults in the oldest old age group, with varying levels of sedentary behaviour and frailty status. The presented strategies appear to be acceptable, appropriate, safe, and high levels of adherence were observed. Participant feedback will be used to refine the intervention.

Introduction: The surge of disabled older people have brought enormous burdens to society. The aim of this study was to examine the impact of long-term care insurance (LTCI) implementation on mortality and changes in physical ability among disabled older adults.

Methods: This was a prospective observational study based on data from the government-led LTCI program in a pilot city of China from 2017 to 2021. Administrative data included the application survey of activities of daily living (ADL), the baseline characteristics and all-cause mortality. Return visit surveys of ADL were conducted between August 2021 and December 2021. A regression discontinuity model was used to analyze the impact of LTCI on mortality.

Results: A total of 12,930 individuals older than 65 years were included in this study, and 10,572 individuals were identified with severe disability and participated in the LTCI program. LTCI implementation significantly reduced mortality by 5.10 % (95 % CI, -9.30 % to -0.90 %) and extended the survival time by 33.74 days (95 % CI, 13.501 to 53.970). The ADL scores of the LTCI group dropped by 2.5 points on average, while the ADL scores of those did not participated in LTCI dropped by 25.0 points. The heterogeneity analysis revealed that the impact of LTCI on mortality reduction was more significant among females, individuals of lower age, those who were married, cared for by family members, and who lived in districts with rich care resources.

Conclusions: LTCI implementation had a favorable impact on the mortality and physical ability of participants. This research marks the first comprehensive exploration of the potential health benefits associated with the implementation of LTCI, providing valuable perspectives that can inform policy making and enhance the development of robust long-term care systems in developing countries.

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.

Introduction: One of the most important consequences of hospitalisation in older patients is sarcopenia. This study aims to determine the impact of hospitalisation on muscle mass, functional status, nutritional status, and short-term clinical outcomes.

Methods: A prospective study of patients admitted to an Acute Geriatric Ward between 1st November and 30th December 2022. Muscle ultrasound, utilising Point of Care Ultrasound (POCUS) at the bedside, was employed to estimate rectus femoris muscle thickness (MT), area (Ar), pennation angle (PA), and fascicle length (FL) at the time of hospital admission, 3 days post-admission, and at hospital discharge.

Results: 30 patients included, with a median age of 84 years (SD 72-93), 63.3% male, and 70% Clinical Frailty Scale score ≥ 4. Barthel Index and Functional Ambulation Category revealed median values of 72.33 and 3.87 respectively. The Global Deterioration Scale median was 2.47. Mini Nutritional Assessment Short-Form (MNA) and total serum protein showed median values of 7.40 and 6.35 respectively. The median length of hospital stay was 5.79 days, with an inpatient mortality rate of 10% and a 53.3% incidence of delirium. Ultrasound showed a decrease in PA by 36.31%, Ar by 34.30%, and MT by 24.50%, and an increase in FL by 10.47%. Sarcopenia classification at admission and discharge revealed an increase in the mean index from 5.04 to 7.74.

Conclusions: In our cohort of patients admitted to an acute geriatric unit, POCUS identified real-time decreases in MT, Ar, and PA at the muscular level before these manifested as functional changes. It demonstrated an inverse relationship between frailty and muscle morphology as living with frailty was associated with further decreases in muscle mass at discharge. The study also established a direct relationship between MNA, muscle thickness, PA, and fascicle length at discharge. POCUS assessment of muscle mass could indirectly predict outcomes and guide decisions to address muscle mass abnormalities.

Introduction

Older people living with frailty are at high risk of adverse clinical outcomes following emergency laparotomy, including early death, hospital readmission and functional decline. Despite this, there is a paucity of literature exploring patient experience of surgery in this group, particularly following hospital discharge. As a result, there is limited information to guide the development of service delivery models that support optimal post-operative recovery and improve overall experience

Methods Twenty older people, aged ≥65 years, with a Clinical Frailty Scale score of ≥ 4 and who had undergone emergency laparotomy were recruited from eight participating hospital sites. Participants were interviewed at 3 weeks following their surgery, or the earliest convenient date. Semi-structured interviews were undertaken either face to face or via telephone and explored the peri-operative and early recovery experience. Data were analysed using reflexive thematic analysis

Results Participants described physical, psychological, and social implications following emergency laparotomy which extended further than hospital discharge. Recovery was perceived to be an ongoing and slow process of returning to ‘normal self’ however participants displayed resilience towards achieving this by ‘knuckling down’ and ‘pushing forward’. The experience of hospital care was generally positive, but lack of access to discharge advice and community follow up left some participants feeling ‘abandoned’ and uncertain once they returned home. Many were reliant on family support during this period

Conclusions Older people living with frailty experience multifaceted consequences of emergency laparotomy that result in a prolonged recovery period. Multi-disciplinary post-operative care pathways are essential in addressing the holistic care needs of this group following surgery. The provision of robust discharge information and enhanced access to support in the community could improve patient experience and facilitate ongoing recovery at home.

Introduction: A growing body of evidence suggests that metabolic syndrome is associated with endocrine disorders, including thyroid dysfunction. Thyroid dysfunction in patients with metabolic syndrome may further increase the risk of cardiovascular disease, thus increasing mortality. This study was conducted to assess thyroid function in patients with metabolic syndrome and to assess its relationship to components of metabolic syndrome.

Methods: A cross-sectional study was carried out among 170 geriatric patients. Anthropometric measurements (height, weight, waist circumference) and blood pressure were taken. Fasting blood samples were analyzed for glucose, triglycerides, high-density lipoprotein (HDL) cholesterol, and thyroid hormones (triiodothyronine, thyroxine, and thyroid-stimulating hormone).

Results: Thyroid dysfunction was observed in 31.9% (n = 54) of patients with metabolic syndrome. Subclinical hypothyroidism (26.6%) was the main thyroid dysfunction followed by overt hypothyroidism (3.5%) and subclinical hyperthyroidism (1.7%). Thyroid dysfunction was much more common in women (39.7%, n=29) than in men (26%, n=25), but not statistically significant (p=0.068). The relative risk of having thyroid dysfunction in women was 1.525 (CI: 0.983-2.368) compared to men. Significant differences (p = 0.001) were observed in waist circumference between patients with and without thyroid dysfunction and HDL cholesterol that had a significant negative correlation with thyroid-stimulating hormone.

Conclusion: Thyroid dysfunction, particularly subclinical hypothyroidism, is common among patients with metabolic syndrome and is associated with some components of metabolic syndrome (waist circumference and HDL cholesterol).

Background: This study aims to investigate the relationship between frailty and in-hospital cardiopulmonary resuscitation (CPR) outcomes in the COVID-19 pandemic.

Methods: The study was carried out in a tertiary hospital in Scotland and included all patients over the age of 18 who had an in-hospital CPR attempt between April 2020 and March 2022. Patients were identified via the pre-existing National Cardiac Arrest Audit Database which was collected prospectively. Data collected from this included age, sex, initial arrest rhythm, return of spontaneous circulation (ROSC) and in-hospital mortality. The electronic and paper patient notes were retrospectively reviewed to calculate a Rockwood clinical frailty scale (CFS) and Charlson comorbidity index (CCI). The data was stratified in to frail (CFS ≥5) and non-frail (CFS <5) cohorts.

Results: 65 patients were included in the study. In univariate analysis, there was a significant difference between the frail and non-frail groups in age (p=0.006), ROSC (p=0.02) and survival to discharge (p=0.004). Only 10 out of 34 (29.4%) frail patients had ROSC and of those only 3 (8.8%) survived to discharge compared to 35.3% of non-frail patients. In a binary logistic regression, there was a significant association between frailty and both ROSC (adjusted OR 3.31 [95% CI: 1.12-9.78}) and survival to discharge (adjusted OR 6.33 [95% CI: 1.48-27.13]) and no significant association with age, CCI or sex.

Conclusion: The findings support the relationship between frailty and poor CPR outcomes independent of age and co-morbidity.

Background: Older adults are the fastest-growing and most sedentary group in society. With sedentary behaviour associated with deleterious health outcomes, reducing sedentary time may improve overall well-being. Adults aged ≥75 years are underrepresented in sedentary behaviour research, and tailored strategies to reduce sedentary time may be warranted for this subset of older adults. The development of an intervention to reduce sedentary behaviour in adults aged ≥75 years using co-production and behaviour change theory is reported.

Methods: Four co-production workshops with community-dwelling older adults aged ≥75 years were held between October-December 2022. The intervention development process was informed by the Behaviour Change Wheel (BCW) and Theoretical Domains Framework (TDF). Audio recordings and workshop notes were iteratively analysed, with findings used to inform subsequent workshops.

Results: The co-production group consisted of six community-dwelling older adults aged ≥75 years and two researchers. The developed intervention consists of four components (activity monitoring, educational material, group sessions and researcher follow-up), maps to 24 behaviour change techniques and targets barriers to reducing sedentary time. Participants were receptive of the co-production process.

Conclusions: Integrating co-production with the BCW can provide several benefits, with the BCW providing structure to the intervention development process, and co-production increasing the likelihood of the developed intervention being viewed as feasible by older adults. Furthermore, coding intervention components to the BCW may further our understanding of what approaches are successful or unsuccessful at influencing behavioural change. Transparent reporting of the intervention development process may benefit researchers developing interventions with older adults. Future research will pilot the co-produced intervention.