SP - Other medical conditions

Introduction

• Delirium is common in hospitalized older patients. It is associated with increased mortality, poorer functional outcomes and increased length of stay.
• It has also been shown to be positively associated with level of co-morbidity in older postoperative patients.
• The aims of the study is to assess the correlation between delirium and co-morbidity in older medical inpatients. It also aim to determine the effect of gender on this association.

Method:

• This was a prospective, cross-sectional analysis carried out as part of a Quality Improvement Project on screening for delirium in older patients admitted acutely on medical wards from 6th to 12th October 2022.
• Patients were included if they were 65 years and over.
• Exclusion criteria were patients younger than 65 years. Patients with incomplete data were also excluded from analysis.
• Patients were screened for delirium using the 4-AT screening tool which is well validated.
• In addition the patients’ co-morbidities were assessed using the age-adjusted Charlson’s Comorbidity Index(CCI).
• The SPSS 29 IBM software was used for statistical analysis. Baseline characteristics were calculated using descriptive statistics. Pearson’s correlation co-efficient and linear regression analysis were used to calculate correlation.

Results:

• 233 patients in total were assessed - 119 males and 114 females.
• Median age was 79.4 years in males (Interquartile range – IQR – 11) and 83.5 years in females (interquartile range – IQR – 12).
• Overall mean age was 81.6 years (SD 8.1).
• The prevalence of likely delirium was 32.2 %.
• There was a statistically significant positive correlation between 4-AT and CCI  (r=0.236; p<0.001).
• This effect was stronger in male than female patients (r=0.275, p=0.002 vs r=0.197;p=0.035 ; respectively).

Conclusion:

• There was a statistically significant positive correlation between elevated 4AT score and CCI in acutely hospitalized older medical patients. This correlation was stronger in males.

  • The association needs more studies to validate these findings.

Introduction:

The Enhanced Health in Care Homes Framework recognises personalised advance care planning (ACP) as a key component of optimal healthcare for care home residents. We established a multi-disciplinary care home team providing comprehensive geriatric assessment (CGA), structured medication review (SMR) and advance care planning (ACP) to a pilot cohort of frail residents in 17 care homes. We aimed to explore the acceptability and perceptions of proactive ACP alongside CGA from the perspective of resident’s next-of-kin (NOK), primary care staff and care home managers (CHMs).

Methods:

Data was collected using standardised questionnaires between February-September 2022. Data were analysed using qualitative content analysis. This was undertaken independently by two lead authors, after which codes and categories were identified through a collaborative approach and triangulation.

Results:

Four categories emerged from NOK data: 1) Perceived benefit of frailty specialist review, 2) Perceived improved knowledge of the individual through holistic assessment, 3) Sensitive conversations were perceived to have been handled well, but this was sometimes challenging over the phone, 4) Families felt empowered in shared decision making. Six categories emerged from primary care feedback: 1) Perceived benefit of holistic reviews, 2) Improved information sharing using same clinical system, 3) Specialist frailty involvement supporting GP learning, 4) Challenges with set-up, 5) Perceived avoidance of admissions following reviews, 6) Time and financial savings for NHS Four categories emerged from CHM feedback: 1) Perception that medical reviews were overdue, 2) Reduced care home staff workload through saving of time, 3) Specialist review and 4) Empowering staff to avoid admissions.

Conclusions:

This evaluation identified key feedback themes in relation to the perceived value and acceptability of a dedicated care home team performing CGA based ACP. Stakeholders expressed positive views about the service, suggesting benefits for individual residents, primary and community healthcare staff, and the wider healthcare system.

Introduction

Resistance exercise is an effective intervention for older people at risk of, or living with, sarcopenia and frailty. Surveys of current UK practice in exercise prescription for these conditions found that  resistance exercise was offered in only 9% of departments and was often not optimised for sarcopenia and frailty. The Benchmarking Exercise Programmes for Older People (BEPOP) project is a joint British Geriatrics Society and AGILE initiative to promote best practice in the prescription of resistance exercise for older people.

Methods

Using an online data collection tool, 10 services delivering exercise interventions to older people from across the UK submitted anonymized details of baseline assessment (including demographics), exercise prescription and progression, and outcomes, for up to 20 consecutive patients referred to their services with probable sarcopenia, frailty, falls, and reduced mobility. Descriptive data were reviewed and analysed by an expert panel comprising physiotherapists, geriatricians, and exercise specialists.

Results

Data were analysed for 188 patients with a mean age of 80 years (range 60-101). At the time of referral, 154 (83%) patients did not have a diagnosis of sarcopenia. At baseline, 115 (61%) patients received an objective assessment of muscle strength. The most common modality of resistance exercise prescribed was bodyweight exercises (n=173, 92%) followed by resistance bands (n=49, 26%). Progression of exercise programmes was predominantly through increased repetitions (n=163, 87%) rather than increased load. Forty-one (24%) patients did not undergo any review to inform progression of exercise dose. Fifty patients (30%) patients did not have re-assessment of the outcome measures recorded at baseline on completion of the prescribed exercise programme.

Conclusion

Multiple opportunities exist to improve both the diagnosis and assessment of sarcopenia, and the prescription, delivery, and monitoring of resistance exercise. BEPOP will provide individualized benchmarking reports to each site to facilitate quality improvement and local service development.

Introduction: Medication non-adherence is estimated to cost the NHS >£500 million a year in preventable morbidity, mortality and health service use. Multi-compartment medication compliance aids (MCAs) are provided in an effort to promote adherence, despite opposing recommendations from NICE and the Royal Pharmaceutical Society. This study aimed to understand the views of patients and carers of MCAs, including those who have declined or discontinued the use of a pharmacy-filled medication compliance aid (pMCA).

Method: A researcher-administered questionnaire survey of older adults (“users”) and carers, who used, declined or discontinued a pMCA. Participants were recruited from inpatient, outpatient and community services at a central London NHS trust. Thematic analysis was conducted by two independent researchers to identify overarching themes.

Results: 88 users and 88 carers were interviewed. The majority of pMCAs were started by healthcare professionals or requested by the carer due to polypharmacy. 12 of 61 users (20%) did not know why a pMCA had been provided, with only 6 requesting the aid themselves. 5 (8%) current pMCA users considered returning to taking medicines from their original packaging. Themes common to both groups included polypharmacy and poor product design. A theme identified solely in the patient group was autonomy and independence, while carers commented on time, waste and sustainability, and responsibility and associated mistakes. For the most part, carers and users perceived MCAs as useful tools to assist medication adherence.

Conclusion: pMCAs are often issued to manage complex medication regimens which are cognitively overwhelming, sometimes at the expense of patient autonomy. Healthcare professionals should aim to reduce the need for pMCAs through individualised medication reviews and rationalisation and improvement of pathways to obtain medicines. If their use is unavoidable, the design of the product and healthcare systems surrounding their use should be optimised to improve the user experience.

Background Prehabilitation in clinical trials improves fitness, improves quality of life, reduces complications, and reduces hospital length of stay It is not standard of care in routine clinical practice. This prospective observational study reports the outcomes of a clinical AHP prehabilitation service for older people undergoing major cancer surgery. Methods The LUHFT Prehab service commenced in August 2017, patients prior to major abdominal surgery for cancer were eligible for referral, this was inclusive of 8 different surgical specialties. Referred patients were invited to attend a multi-disciplinary prehabilitation clinic inclusive of physiotherapy, occupational therapy and dietetic support. In a review of the past 12 months clinical frailty score was recorded at baseline and pre surgery. Patients were given individualised exercise, wellbeing, and nutrition plans, and provided with support via 121 or group based follow up. Where distance was a barrier, telephone clinics were undertaken. Results Over a 12-month period 477 patients were referred over the age of 65, of these 436 underwent baseline frailty assessment. Of these 380 went on to have surgery with an average period of 40 days between initial prehab assessment and their elective admission. In these patients 50 scored 5 or above on the clinical frailty scale, 105 fell within the vulnerable category and 163 in managing well at baseline. Of those patients reassessed pre surgery 100% of patients with a frailty score of 5 or above either improved or maintained their score. Of those that scored a frailty score of 4, 94% either improved or maintained their score. Conclusion A prehabilitation service is feasible and improves frailty in the lead up to major abdominal elective surgery in a cohort that would otherwise be expected to decondition due to the nature of their disease. Prehabilitation should be part of standard care for older patients undergoing cancer surgery.

Introduction

Alcohol use disorder (AUD) in older adults is increasingly common, under-recognised and under-treated within acute hospitals.

Methods

Consecutive patients seen by the Alcohol Care Team (ACT) at an acute NHS trust between January-April 2021 were invited to take part in a service evaluation.

Baseline demographic and clinical data was collected in addition to community alcohol service referrals for all patients.

For older adults (>64years), Older People’s Mental Health (OPMH) referral and hospital use data (ED attendances and admissions) in the 12 months prior/post index admission were also collected.

Results

Of 280 patients seen by the ACT during the 3-month period, 87 (31%) were older adults and 75% were male. Older adults resided in more affluent neighbourhoods compared to patients under 65 (p = 0.002).

Referral to community alcohol services was predicted by younger age (p<0.001), medically assisted withdrawal during admission (MAW) (p <0.001) and scoring as possibly alcohol dependent (p= 0.006) on the Alcohol Use Disorder Identification Test (AUDIT) screening tool.

In binary multivariate logistic regression considering age, sex, MAW and AUDIT category, referral onto alcohol services remained highly significant for age, with older adults less likely to be referred (odds ratio 0.029, CI: 0.007 to 0.125, p<0.001).

In older adults drinking at higher risk/possibly dependent levels, only 4.3% (n=2/47) were referred to alcohol services compared to 66.2% (n = 96/145) in under 65s. Older adults were more often signposted or not referred due to confirmed/perceived cognitive impairment.

No significant difference in use of hospital services was found for the 12 months after the index admission.

Conclusions

Older adults are less likely to be referred to community alcohol services, despite evidence they are drinking at higher risk/dependent levels. Further exploration into the reasons behind this is required to help inform development of appropriate pathways and services for this patient group.

Introduction

Frailty is a syndrome associated with increasing numbers of elderly hospital admissions and prolonged inpatient stays (Archibald et al, Geriatrics, 2020, 20, 17). In 2015, an estimated 14% of inpatients in the UK were considered to have a degree of frailty, representing an approximate annual cost to the NHS of £5.8 billion (Soong et al, BMJ Open, 2015, 5, e008456; Han et al, Age and Aging, 2019, 48, 665-671). Frailty is poorly defined; there are discrepancies in existing literature on how to best quantify frailty. It is recognised there is a higher risk of adverse outcomes in this vulnerable population due to lack of physiological reserve (Clegg et al, The Lancet, 2013, 381, 752-762). The Hospital Frailty Risk Score (HFRS) is a recent development to measure frailty and identify patients at risk (Gilbert et al, The Lancet, 2018, 391, 1775-1782). This study sought to establish whether the HFRS could be used in patients with degenerative spinal disease, undergoing decompression surgery, to predict post-operative outcomes. 

Methods

A retrospective service evaluation of eligible patients in Leeds Teaching Hospitals Trust between March 2018 - March 2020. The exposure was the patients’ HFRS; the outcome was the length of stay (LOS) until physiotherapy discharge. Data was sourced from electronic records.

Results

214 patients were identified with an available HFRS value. Patients were categorised as low, intermediate or high frailty. Kruskal-Wallis test for LOS and categorical HFRS: X² =8.673, p<0.05. The median HFRS value was 1.25 (interquartile range 0.00 to 3.35). Mann-Whitney U test for LOS and numerical HFRS: W=29297, p<0.05. 

Conclusions

The results of this study complement pre-existing studies of similar natures, evaluating frailty scoring and post-operative outcomes. Thus supporting the potential for standardised use of HFRS alongside holistic patient examination to streamline pre-assessment, improve outcomes and reduce the NHS frailty burden. 

Introduction: The COVID-19 pandemic has resulted in many people experiencing bereavement in challenging circumstances. In April 2020 at a large London Trust, a “Bereavement Welfare Hub” (BWH) was established to offer support and advice by telephone to relatives and carers of all adults who died as inpatients. Data from these calls has been used to examine and learn from experiences of the bereaved at this time.

Methods: Data from BWH call records regarding 809 adults who died at the Trust in March - May 2020 were collated and analysed quantitatively. A random selection of 149 call records were examined using thematic analysis.

Results: 809 adults died at the Trust between March and May 2020. The mean age at death was 76 (SD=14) and 86% of deaths occurred on medical wards (outside intensive care). Bereavement calls were completed in 663 (82%) of cases. From analysis of call records, several themes that influenced the bereavement experience were identified. These included support from family and community, communication and contact with the dying person, support from bereavement services and ability to carry out usual rituals associated with dying.

Conclusions: Age is a significant risk factor for death from COVID-19 and the majority of deaths have occurred on medical wards. Improving hospital care of dying patients during the pandemic or at any time is relevant to geriatricians and other healthcare professionals working with older people. Our analysis identifies several factors which positively or negatively influenced the experiences of people bereaved during the first wave of COVID-19. From these findings, recommendations have been made which have the potential to improve the bereavement experience, particularly during the pandemic era.

Introduction

The health benefits of physical activity for older people are well recognised and include reduction in falls, improvement in frailty status and physical function. Nonetheless, physical inactivity remains a significant problem among older adults. This study aimed to determine the feasibility and acceptability of implementing online volunteer-led group exercise for community-dwelling older adults.

Methods

This pre-post mixed methods study was conducted among older adults attending community social clubs. Eligible participants were aged ≥ 65 years, able to walk independently, and able to provide written consent. The intervention consisted of a once weekly volunteer-led online group chair-based exercise. The primary outcomes were the feasibility and acceptability of the intervention. Secondary outcomes included physical activity levels measured using the Community Health Model Activities Program for Seniors (CHAMPS) questionnaire, functional status (Barthel Index), and health-related quality of life (EQ-5D-5L). Outcomes were measured at baseline and at 6 months.  Trials registration: NCT04672200.

Results

Nineteen volunteers were recruited, 15 completed training and 9 were retained (mean age 68 years, 7 female). Thirty participants (mean age 77 years, 27 female) received the intervention and attended 54% (IQR 37-67) of exercise sessions. One minor adverse event was reported. Participants had no significant changes in secondary outcome measures, with a trend towards improvement in physical activity levels. The intervention was acceptable to volunteers, participants, and staff. The seated exercises were perceived as safe, manageable and enjoyable. Volunteers were relatable role models providing positive vicarious experiences that improved participants confidence to exercise within a friendly, non-judgmental environment. Technological issues, or reluctance to learn how to use technology were barriers to the intervention. The social interactions and sense of belonging motivated participation. 

Conclusions

Trained volunteers can safely deliver online group exercise for community-dwelling older adults and the intervention was feasible and acceptable to older adults, volunteers and club staff.

Introduction

Older people living in care homes sometimes experience episodes of acute functional decline. These represent a diagnostic challenge to healthcare professionals and can result in antibiotic prescriptions or hospital admissions, though this may not always the most appropriate management strategy. We aimed to understand how episodes of acute functional decline are recognised, managed and escalated by care home staff in the UK.

Method

This was a qualitative interview study with UK care home staff, including managers, nurses and carers. Participants were recruited through advertisements circulated via email, social media and word of mouth. Semi-structured interviews were conducted over the phone between January 2021 and April 2022. Thematic analysis was facilitated by NVivo software. 

Results

25 care home staff were interviewed. Participants described feeling confident in recognising when residents were less well than usual, especially if they knew them well. However, they sometimes felt it was difficult to differentiate between an ‘off day’ and something more significant. Most participants talked about clear early communication amongst the team to flag a resident of concern. Initial management steps in the care home included checking clinical observations and doing a urine dipstick. Many participants talked about considering the underlying cause for deterioration. Some participants felt comfortable monitoring residents for a few days themselves or trying a simple intervention. Others preferred escalating directly to outside clinical support.  Triggers for escalation included perceived severity of illness, gut feeling or failure to respond to initial supportive management.

Conclusions

These results highlight the skill base of care home staff. However, it has also helped to identify areas for additional support and training including the use and interpretation of the urine dipstick. The findings of this study are being used to inform the design of a feasibility prospective cohort study of UK care home residents.