bluuebunny/crossref_metadata_2025 huggingface dataset:
1655 FRONT DOOR FRAILTY: A QUALITY IMPROVEMENT PROJECT TO REDUCE PREVENTABLE EMERGENCY ADMISSIONS FOR OLDER ADULTS
Authors: Jackson E , Millington K , Roth K , Parkinson F , Gordon A , Evans B
Published: July 2023

Background

Up to 17.5% of admissions for older adults with frailty may be Preventable Emergency Admissions (PEAs). PEAs are costly and expose patients to complications including deconditioning, delirium, malnutrition and nosocomial infections. Royal Derby Hospital (RDH) has 1159 beds and cares for a population of around one million. The Frailty Emergency Assessment Team (FEAT) operates within the Emergency Department (ED) and Medical Assessment Unit. FEAT is multi-disciplinary, comprising nurses, physiotherapists and occupational therapists.

Aim

To reduce the number of PEAs for older adults presenting to RDH.

Design

We integrated a Geriatrician into FEAT with the aim of reducing PEAs through early medical reviews. Suitable patients were identified through referral from ED and routine screening of the patient information system. To support consistent medical reviews and automate data collection we created an e-form embedded within the Electronic Patient Record. This captured details and outcome of medical reviews including Clinical Frailty Score (CFS), problem list, medication review and ‘Medically Stable for Discharge’ (MSFD) status.

Results

Between 7th February 2022 and 20th February 2022 68 medical reviews were collected on the e-form. 72% were assessed first by an ED clinician. 81% had a CFS of 5-7 and 7% had a CFS of 8. The most common presenting complaint was ‘fall(s)’ (25%) followed by ‘clouded consciousness’ (13%). 66% of FEAT physician reviews resulted in planned discharge from ED, 13% of which avoided an admission planned by ED. Of 68 patients reviewed 42 (62%) were MSFD. Of these 29 (69%) were discharged home, 11 (26%) were admitted to a ward to await interim beds or new care package, one (2%) patient was discharged to a care home and one (2%) to another health care facility.

Conclusion

Our intervention reduced PEAs for older adults presenting to RDH. The e-form automated data collection successfully.
1587 ASSOCIATION BETWEEN HANDGRIP STRENGTH-BASED MOTORIC COGNITIVE RISK SYNDROME AND THE RISK OF COGNITIVE IMPAIRMENT
Authors: Chen Z , Ho M , Chau P H
Published: July 2023

Background

Motoric cognitive risk syndrome (MCR), characterised by slow gait speed (GS) and subjective cognitive complaints, is a simple way to screen older adults at high risk of dementia. In primary care service, however, assessing GS may still be a challenge due to the short consultation time and space constraints common in general practice. Therefore, there is a need to explore alternative MCR subtypes with motor domains that can be measured conveniently. This study aimed to explore a new subtype of MCR, using low handgrip strength (HGS) as the motoric phenotype, and examined its association with the incidence of cognitive impairments among the Chinese community-dwelling older adults.

Methods

We used four-wave data (2011-2018) of participants (≥60 years) in the China Health and Retirement Longitudinal Study. We investigated two MCR subtypes. First, MCRg was defined in the literature as the coexistence of slow GS and cognitive complaints without dementia or morbidity disability. Then, we defined a new subtype, MCRh, by replacing slow GS with low HGS. Cox proportional hazards models were used to examine the association between baseline MCR subtypes (MCRg and MCRh) and incident cognitive impairment, controlling for sociodemographic characteristics, lifestyle behaviors and health conditions.

Results

Of 3325 participants (Mean age: 66.7±5.7, males: 54.9%), 5.2% had MCRg and 5.4% MCRh. Based on Cox models, both MCR subtypes were associated with the increased risk of cognitive impairment, with adjusted hazard ratios (95% CI) of 1.821 (1.402 to 2.368) for MCRg and 2.008 (1.567 to 2.574) for MCRh.

Conclusion

Low HGS, which can be quickly measured and requires no additional space, may be considered as a promising motoric phenotype of MCR subtypes. This study preliminarily supports the potential utilization of the HGS-based MCR subtype for early risk identification of cognitive impairment in primary care settings.
1474 DIABETES MANAGEMENT IN OLDER ADULTS WHO FALL: A RETROSPECTIVE COHORT STUDY
Authors: Burgess A J , Williams D M , Collins K , Roberts R , Burberry D J , Stephens J W , Davies E A
Published: July 2023

Introduction

Type 2 diabetes mellitus (T2D) is associated with poor health outcomes and tight glycaemic targets are questionable in those aged over 70 years. We examined whether people with T2D admitted to emergency department (ED) with a fall, were more likely to have greater frailty, co-morbidity burden, or risk factors for falls and whether use of insulin or gliclazide was associated with poor clinical outcomes.

Methods

The Older Persons Assessment Service (OPAS) is a local emergency department service which accepts patients on frailty criteria. The OPAS databank was retrospectively analysed for people with T2D admitted with a fall between June 2020-September 2022. We examined clinical outcomes relating to medication, age, Charlson co-morbidity index (CCI) and clinical frailty score (CFS).

Results

1081 patients were included: 294 (27.2%) with T2D and a mean HbA1c of 53.9 (±15.8) mmol/mol [7.1%]. People with T2D had a similar mean CFS and age compared to those without T2D, but higher mean CCI (7.0±2.2 vs 5.9±2.1, p<0.001). Of those people with T2D, 175 (59.5%) and 240 (81.6%) had a HbA1c ≤53 mmol/mol [7.0%] and ≤64 mmol/mol [8.0%], respectively. In total, 48 (16.3%) people with T2D were identified to have a capillary blood glucose below 4.0 mmol/L on admission to the emergency department. People with T2D treated with insulin and/or gliclazide had a greater mortality (36.6% vs 23.6%, p<0.05), greater frequency of hypoglycaemia (35.4% vs 11.8%, p<0.001), and greater HbA1c (65.5±17.2 mmol/mol [8.2] vs 48.9±12.1 mmol/mol [6.6%]) compared to those who used other agents. People with T2D were not more likely to live in deprived areas.

Conclusion

Falls are a significant burden, and hypoglycaemia-inducing medication may contribute to the greater mortality observed in people with T2D. Clinician awareness can support de-prescribing for patients with frailty and HbA1c <64mmol/mol. There should be increased awareness of the impact of hypoglycaemia, especially in those using insulin or gliclizade.
1559 USING QUALITY IMPROVEMENT METHODS TO DESIGN A WEEKLY WARD-BASED TEACHING PROGRAMME
Authors: Gill G , Wilkinson I , Collins S , Eleftheriades C
Published: July 2023

Introduction

A weekly ward-based teaching programme was designed and implemented using quality improvement methodology. 10 topics were identified to be covered during each 4-month rotation. 1) Topic of the week introduced via a presentation in the weekly teaching session; 2) Daily topic discussions at ward level.

Method

7 wards. PDSA 1 (weeks 1 and 2): Weekly poster with the topic and a daily fact / question PDSA 2 (week 3 onwards): a) Software introduced to enable interaction in the teaching session b) Departmental WhatsApp used to send out daily questions. PDSA 3: a) New topics selected b) More staff groups added to WhatsApp group c) Questions weekly for each ward to ‘answer’ in the WhatsApp group

Results

Cycle 1 – little daily ward level discussion. Generating discussion in weekly teaching difficult. Cycle 2 - more engagement with both discussions. Variation in (MDT)staff group awareness. Daily teaching not habitual everywhere. Nursing staff more engaged with prompt cards than via Whatsapp. It was clear that each ward should be supported to have a different approach to delivering the teaching. Not all staff could access to weekly teaching sessions. Cycle 3 – more ward level ownership and interaction in the virtual space. The wards that have gained the most benefit from the teaching have made the questions a fixed part within their morning routine and include the entire MDT in five-minute discussion around the questions.

Conclusion

Staff working in these wards were generally positive about the weekly topic style. Having clinical leaders who are invested in teaching can support daily - cooperation and “buy-in” from those in senior roles is crucial for the development of this learning culture. This work has demonstrated some of the challenges of teaching a diverse multidisciplinary team to make information and learning accessible and useful for all.
1589 CHARACTERISTICS, TREATMENT AND HEALTHCARE UTILISATION OF PATIENTS WITH XEROSTOMIA IN PRIMARY CARE SETTINGS IN THE UNITED KINGDOM
Authors: Hosnijeh F Saberi , Heaton D , Gomez J
Published: July 2023

Introduction

Xerostomia, also known as dry mouth, is prevalent in older populations and associated with key determinants such as continual use of medication, radiation, and chronic diseases. Xerostomia significantly increases the risk of experiencing demineralisation, dental caries, tooth sensitivity, candidiasis, and other oral conditions that may negatively affect quality of life. An effective strategy to manage the risk of dental caries for patients with xerostomia is the prescription of high-fluoride products with proven efficacy. The aim of this study was to provide evidence on the burden of xerostomia, patient characteristics, treatments, and healthcare resource use in this patient population in the United Kingdom.

Method

A retrospective observational study was conducted including all patients aged ≥16 years with a first diagnosis of xerostomia between 01/04/2015-31/03/2020 in the Optimum Patient Care Research Database, a primary care database. Patients with <12 months’ baseline and follow-up data were excluded.

Results

11,731 patients with a mean age of 67.93 years (SD 15.64) newly diagnosed with xerostomia were included. 72.27% of patients were >60 years and 65.3% were females. Patients aged ≥65 years received a median of 5 (Q1-Q3: 4-6) drug classes in the baseline period. Analgesic agents (80.6%), cardiovascular drugs (70.3%), antidepressants and antipsychotic agents (57.3%), and antihypertensive agents (47.6%) were common prescriptions reported before the diagnosis of xerostomia. Patients had 24.2 primary care visits with the associated costs of £727.66 per patient-year during follow-up. Only 2.2% of patients received high-fluoride toothpaste, whereas 99.6% of patients were prescribed artificial saliva and 16.3% received saliva stimulants.

Conclusions

The majority of patients aged ≥65 years had chronic diseases for which they received ≥4 medications in the baseline period. Although xerostomia is predominantly managed in primary care, few patients are prescribed high-fluoride toothpaste, which is a cost-effective and simple way to reduce the inevitable risk of dental caries.
1436 CLINICAL OUTCOMES OF OLDER HOSPITALISED ADULTS LIVING WITH FRAILTY IN NORTHERN TANZANIA: A PROSPECTIVE MULTICENTRE STUDY
Authors: Davidson S L , Rayers G , Motraghi-Nobes S M , Bickerstaff E , Emmence L , Kilasara J , Lyimo G , Urasa S , Mitchell E , Dotchin C L , Walker R W
Published: July 2023

Introduction

As global populations age, healthcare systems are facing challenges posed by multimorbidity, disability and geriatric syndromes. In high-income countries, frailty is a strong predictor of poor hospital outcomes. Comprehensive Geriatric Assessment is effective but resource-intensive and unavailable in sub-Saharan Africa where specialist geriatric training and allied health infrastructure are limited.

Aim

To establish clinical outcomes of older adults with frailty admitted to hospital in northern Tanzania.

Methods

All adults aged ≥60 years admitted to medical wards at four hospitals were invited to participate. Participants were screened for frailty using the Clinical Frailty Scale (CFS). The primary outcome was inpatient death, with secondary outcomes including length of stay, 30-day readmission and delirium (confirmed using the Confusion Assessment Method [CAM]). Outcomes for frail (≥5 on CFS) and non-frail participants (1-4 on CFS) were compared.

Results

Over 6 months, 308/540 patients admitted participated. Reasons for non-participation included death (n=34) and discharge (n=159) before researcher attendance. Mean age of participants was 74.9 years and 154 (50.1%) were female. Of these, 205 (67%) participants had a CFS ≥5. 21 (14.9%) frail participants died, compared with 5 (6.4%) in the non-frail group (Chi-squared, p=.095). Length of stay and re-admission rates were higher in frail participants, but differences were not statistically significant. Delirium was diagnosed in 35 (17%) frail participants, compared with 4 (4%) in the non-frail group (Fisher’s Exact test, p=<.001).

Conclusion

Frailty in older adults admitted to hospitals in northern Tanzania is common and associated with significantly higher rates of delirium. Mortality, readmissions, and length of stay were higher in the frail group, but differences did not reach statistical significance. Type II Error (exacerbated by selection bias from non-inclusion of individuals who were discharged, or died, early in their admission) may explain this. Participants will now be followed-up for 12-months to assess outcomes longitudinally.
1667 VARIATION IN ACUTE GERIATRIC MEDICINE ACTIVITY AND OUTCOMES IN SCOTLAND BEFORE, DURING AND AFTER THE COVID PANDEMIC LOCKDOWNS
Authors: Soiza R L , Premathilaka C , Mitchell L , Myint P K ,   the SCoOP collaborative
Published: July 2023

Introduction

The Scottish Care of Older People (SCoOP) collaborative reports outcomes of acute geriatric medicine admissions across Scottish hospitals. The covid pandemic caused major and variable restructuring of acute services across the country. Their impact on activity and outcomes is unknown.

Methods

We collated all SMR01/SMR01E hospital episodes from Public Health Scotland from 1st April 2017 to 31st March 2022 where over 50% of the total episode was spent under acute geriatric medicine (code AB) and the diagnosis was not stroke. Activity and outcomes in 19 major hospitals were compared across financial years 2017-19 (before-), 2020/21 (during-) and 2021/22 (after lockdowns).

Results

Admissions fell by 15% to 36954 in 2020/21 from an average 42566 before recovering to 41971 in 2021/22. Some hospitals were busier than ever in 2020/21 while others saw large reductions in activity. Age, sex and social deprivation profiles differed between hospitals (p<0.001) but remained similar within each hospital at all timepoints. Mortality at 30 days post-admission was 8.5% higher in 2020/21 (17.9% v 16.5% in other years, p<0.001), with 2-fold differences across hospitals. Mean median length of stay (LOS) across hospitals was 11.7 days, compared to 13.6 days in 2017-20, p<0.001. There were up to 17-fold differences in median LOS between hospitals (2-34 days), p<0.001. The impact of the pandemic on LOS within each hospital was variable. Readmission rates at 7 days post-discharge were broadly similar across all years but two-fold differences between hospitals were seen each year (2020/21 4.8%-9.8%, mean 6.8%, p<0.001).

Conclusion

The impact of the pandemic on the activity and outcomes of individual hospitals was widely disparate, probably reflecting variation in how each hospital service responded to the pandemic. Overall activity and LOS were lower and mortality was higher in 2020/21.
1573 SUMMARISING REHABILITATION FOR COVID-19 PATIENTS: A LITERATURE REVIEW AND SYNTHESIS OF COCHRANE REH-COVER
Authors: Georgiev K , McPeake J , Fleuriot J , Shenkin S D , Anand A
Published: July 2023

Introduction

The role of rehabilitation medicine in treating post-acute COVID-19 survivors is currently ill-defined. Recently developed evidence-based initiatives, such as Cochrane REH-COVER, aim to describe the management of COVID-19 patients, but the variance and overlap in intervention types result in clinical uncertainty.

Methods

We collected evidence regarding performed COVID-19 rehabilitation interventions from studies collected by the Cochrane REH-COVER Rapid living Systematic Reviews between March 2020 and February 2022. We extracted a set of studies highlighting details of COVID-19 rehabilitation programmes in adult hospitalised patients. Our exclusion criteria consisted of removing case reports, opinion pieces, guidelines and review articles. We collected information on the delivered service, intervention type and length of rehabilitation where available.

Results

Out of 580 REH-COVER studies, 69 met the inclusion criteria. In-hospital interventions were present in 45 (65%) of cases, 14 (20%) were performed in community or home settings, and 10 (14%) were not explicitly defined. 44% of studies were conducted within the initial wave of COVID-19, in the first half of 2020. Among the intervention categories, 38 (55%) studies consisted of physical therapy, 41 (59%) respiratory training, 7 (10%) neurological treatment, 4 (6%) nutritional therapy and 4 (6%) speech and language therapies. Based on review, we inferred that only 34 (49%) of these studies described a multidisciplinary intervention. Among these treatments, the mean length of rehabilitation was 21 days (95% CI: 13-30), compared to 17 days (95% CI: 8-26) for those with a single intervention. However, these data were not reported in 32 (46%) studies.

Conclusions

There is currently a wide variation in descriptions of rehabilitation interventions for COVID-19 patients. The limited number of papers clearly describing the content and length of rehabilitation programmes reduce the ability to share best practices. Harmonising descriptions of rehabilitation could improve the quality and standardisation of research in this area.
1576 PATIENTS’ AND CARERS’ EXPERIENCES AND PERSPECTIVES OF THE MANAGEMENT OF ANXIETY AND DEPRESSION IN PEOPLE WITH DEMENTIA
Authors: Sinnamon C J , Hughes C M , Barry H E
Published: July 2023

Introduction

Many people with dementia (PwD) are affected by anxiety and depression, leading to significant changes in patient behaviour, carer burden and negative patient outcomes. Anxiolytics and antidepressants are commonly prescribed for PwD and may contribute to potentially inappropriate prescribing. This study aims to explore patients’ and carers’ experiences and perspectives of the management of depression and anxiety in PwD.

Methods

An online discussion forum, Talking Point, hosted by the Alzheimer’s Society, was searched for relevant archived threads and posts. These were identified using 64 search terms such as “depression” and “SSRI”. Data were extracted into Microsoft Word and inductive thematic analysis is ongoing to code the data and identify pertinent key themes.

Results

In total, 3539 posts were identified from 931 registered forum users. Initial findings have highlighted that anxiety and depression were commonly experienced by PwD and many described the difficulties in differentiating depression from dementia during the early stages of dementia. “Initially my wife was treated for depression and anxiety but that soon changed to MCI [mild cognitive impairment], then dementia…” [TP019]. Forum users described the use of anxiolytic and antidepressant medications as a process of trial and error: “The GP gave her sertraline but that didn’t work so now on mirtazapine. Only been 10 days and really makes her sleep just with half a tablet but now crying again” [TP022]. Frank accounts of the symptoms that PwD experienced were shared, highlighting the impact depression and anxiety has on both patients and their carers.

Conclusion

This online discussion forum is a source of rich and valuable data, which may not be accessible through traditional qualitative methods. This study will provide authentic insights on patients’ and carers’ lived experiences of managing anxiety and depression in PwD and will inform further qualitative work with key stakeholders.
1598 A TYPOLOGY OF COMMUNITY-BASED COMPLEX INTERVENTIONS TO SUSTAIN INDEPENDENCE IN OLDER PEOPLE
Authors: Crocker T , Jordão M , Lam N , Ellwood A , Mirza L , Patel I , Patetsini E , Ramiz R , Forster A , Clegg A , Gladman J ,   HTA complex interventions review team
Published: July 2023

Introduction

Provision of community-based health services to support independence of older people, and further research in this area, would be improved by a typology of these complex interventions - thereby enabling evidence synthesis and the identification of effective intervention components. We aimed to produce such a typology in preparation for a systematic review and network meta-analysis.

Methods

The typology was developed based upon the descriptions of these interventions in published reports. This involved four stages: (1) systematic identification of relevant RCTs and related publications; (2) the extraction of descriptions of the interventions (including control/comparison) using the Template for Intervention Description and Replication (TIDieR); (3) a qualitative synthesis generating categories of key intervention features and (4) grouping the interventions based on the categories.

Results

Our search identified 496 reports of 129 studies, involving 266 intervention arms. 19 intervention components were identified: Formal homecare; Physical exercise; Health education; ADL training; Providing aids and adaptations; Nutritional support; Psychological therapy; Technology for communication and engagement; Cognitive training; Engagement in meaningful activities; Care voucher provision; Alternative medicine; Social skills training; Welfare rights advice; Medication review; Monitoring; Routine risk screening; Multifactorial-action from care planning; and Routine review following multifactorial-action from care planning. Multifactorial-action from care planning refers to a process of individualised, multidomain assessment and management resulting in a tailored selection of action components, as in comprehensive geriatric assessment. 63 different intervention types (combinations of these components) were identified.

Conclusions

The typology provides an empirical basis for service planning and evidence synthesis. Target populations are not explicitly integrated and should be considered separately. The components, being broad actions, are likely to endure; further components may be identified. However, the huge potential number of intervention types constitutes a challenge to typical approaches to effectiveness research. We recommend better reporting about organisational aspects of interventions and usual care.
1616 HOW CAN WE ENHANCE COMPREHENSIVE GERIATRIC ASSESSMENT FOR OLDER PEOPLE LIVING WITH FRAILTY IN PRIMARY CARE AND COMMUNITY SETTING
Authors: Mahmoud A , Frost J , Morley N , Whitney J , Goodwin V
Published: July 2023

Background

With advancing age comes the increasing prevalence of frailty and increased risk of adverse outcomes (e.g. hospitalisation). Internationally, models of Comprehensive Geriatric Assessment (CGA) delivery in primary care/community settings vary, and effectiveness is uncertain. CGA is a complex intervention and improving the effectiveness and efficiency of it first requires exploration of how individual components may work and how the intervention can be strengthened.

Aims

To explore how to enhance current CGA, the conditions needed to implement enhanced CGA and the outcomes that older people, families, health and care professionals identify as important.

Methods

A qualitative study using semi-structured interviews with older people and healthcare practitioners working in non-hospital settings with older people in the UK. Data were analysed using an abductive analysis approach. Findings were shared with our stakeholder group involving older people, family members, health and social work professionals.

Results

Twenty-seven people participated including 14 older people and 13 healthcare professionals. We identified limitations in current CGA: the lack of information sharing between different healthcare professionals who are delivering the CGA; communication between older people and their healthcare professionals; and follow-up after conducting the CGA. There was variation in participant perceptions on the provision of digital and remote assessment. However, we found that introducing remote assessment and a designated comprehensive care coordinator might be a viable solution to address the gaps in the current delivery of CGA.

Conclusions

The study identified potential challenges in the implementation of enhanced CGA. However, the participants suggested possible solutions that can be used to overcome these challenges, which aligned with feedback from relevant stakeholders. The next stage of this research will involve using these findings, alongside existing evidence and key stakeholder engagement, to develop and refine a model of enhanced CGA that can then be assessed for feasibility and acceptability.
1617 QUALITATIVE STUDY OF PARTICIPANTS OF A FEASIBILITY TRIAL OF REMOTE PHYSIOTHERAPY FOR EARLY STAGE PARKINSON’S DISEASE
Authors: Malik M , McFarlane K , Gordon A , Skelly R , Chadborn N
Published: July 2023

Introduction

Exercise is beneficial for Parkinson’s disease (PD), but many people struggle to achieve the 150 minutes per a week recommendation. Symptoms of PD or co-morbidity may be barriers for exercise; and physiotherapists can provide expert assessment and tailoring of exercise to accommodate these needs.

Method

We developed a remote physiotherapy intervention using videoconference (Attend Anywhere). An ongoing feasibility trial is assessing this intervention, and a process evaluation seeks to understand the broader context and acceptability of the intervention. Here we present a qualitative study of participants of the feasibility study. We invited participants from the feasibility trial to individual semi-structured telephone or videoconference interview. 14 participants were interviewed. Transcripts were analysed by thematic analysis within two main themes: physical activity and use of digital technology. Participants spoke about their attitudes towards their diagnosis.

Results

Individuals who had come to terms with their PD were more engaged with the exercise regime than participants who expressed a sense of denial. Participants who mentioned the benefits of exercise for reducing or delaying PD symptoms were more likely to report a positive attitude to exercise. In contrast, individuals with co-morbidity, or caring roles, found it more difficult to commit to regular exercise; flexibility of the exercise routine was valued. For the theme of digital technology some participants reported struggling with, technical problems such as interruptions in internet connection, having constrained space to exercise and staying in view of the camera for the physiotherapist. Whilst some participants lacked digital confidence, or expressed a preference for in-person treatment, other participants reported no difficulties or found it more convenient than travelling to clinic.
1523 WHAT PATIENT-REPORTED OUTCOME MEASURES ARE USED IN RESEARCH INVOLVING OLDER ADULTS WITH FRAILTY? A RAPID REVIEW
Authors: Long S O , Hope S V
Published: July 2023

Introduction

The need to develop and evaluate frailty-related interventions is becoming more pertinent as life expectancy increases. Patient-reported outcome measures (PROMsare arguably essential in this field of research and can be defined as “any report of the status of a patient's health condition that comes directly from the patient, without interpretation of the patient's response by a clinician or anyone else” (FDA 2009). Numerous validated questionnaires can be classed as PROMsbut seem inconsistently used, and of uncertain relevance to/for those living with frailty. This rapid review aimed to identify existing PROMsused in research with older people living with frailty.

Method

PubMed and Cochrane were searched (up to 24/11/22). Inclusion criteria were quantitative studies, use of a PROM, and either measurement of frailty or inclusion of older adults as participants. Distinguishing PROMsfrom questionnaire-based clinical assessments was necessary, and criteria were created to do this. 197 records were screened. PROMswere categorised according to the domain they assess, based on a standard set of health outcome measures for older people (Akpan et al, 2018).

Results

90 studies were included. 119 unique PROMswere used 289 times, most frequently the SF-36 (n=23), EQ-5D (n=21) and Barthel Index (n=14). The most frequently assessed outcome domains included “Mood and Emotional Health”, and “Activities of Daily Living”. Outcome domains with fewer usages included “Participation in Decision Making” and “Carer Burden”.

Conclusions

PROM usage in frailty research is highly heterogeneous. The most frequently used PROMsomit outcomes that are important to people with frailty (e.g. Akpan et al 2018, Herrler et al 2021, Mayo et al 2022). Further research should investigate the importance of specific outcomes (and thus identify particularly relevant PROMs to people living at different stages of frailty severity. More consistency of PROM use could facilitate evaluation of different frailty interventions.
1586 OLDER AGE IS AN IMPORTANT PREDICTOR OF NON-REFERRAL TO COMMUNITY ALCOHOL SERVICES FOLLOWING AN INPATIENT EPISODE: FINDINGS FROM
Authors: Phillips C , Band R , Bumpass L , Ghandi S , Sinclair J
Published: July 2023

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.
1603 PROACTIVE ADVANCE CARE PLANNING ALONGSIDE COMPREHENSIVE GERIATRIC ASSESSMENT IN CARE HOMES: A QUALITATIVE FEEDBACK ANALYSIS
Authors: Allcock D , Page E , McCracken S , Thorman E , Marchant R , Worth C , Fraser H , Shipway D
Published: July 2023

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.
1610 IMPACT OF THE INTRODUCTION OF A GERIATRICIAN IN PRE-OPERATIVE ASSESSMENT FOR OLDER ADULTS UNDERGOING ELECTIVE COLORECTAL SURGERY
Authors: Than H P , Phyu E E , Thomas C , Stock E , Kaneshamoorthy M , Jegard J
Published: July 2023

Introduction

About 300,000 people living with Frailty undergo operations annually. Current evidence suggests that comprehensive geriatric assessment (CGA) pre-operatively enhances shared decision making (SDM), equity of access to surgery, length of stay (LOS) and mortality. Multiple NCEPOD reports, the National Emergency Laparotomy Audit (NELA) and National Hip Fracture Database (NHFD) programs have highlighted the unmet need in caring for these patients. Our aim was to introduce a novel combined Geriatrician/Anaesthetist pre-assessment clinic to provide better SDM and perioperative optimisation to improve outcomes for elective colorectal surgery.

Method

We performed combined CGA and Anaesthetic pre-operative assessment in patients undergoing elective colorectal surgery aged ≥65 years between July 2021 to August 2022. Data including Clinical Frailty Score (CFS), LOS, Type of surgery, P-POSSUM Score, 30-day mortality and 90-Day mortality were analysed.

Results

We reviewed 48 patients in 14 months. 69% patients underwent surgery and 27% declined after a comprehensive SDM process. The median age of operated patients was 80 (65-94) compared with 74 in 2020-21. 58% of patients operated were over 80, compared to 24% in 2020-21, prior to clinic inception. The median CFS was 4. 55% of patients had a LOS ≤7days (73% in 2020-21), 32% was 8-14days (18%) and 13% was >14days in hospital (9%) respectively. 32% had a P-POSSUM score of ≥5% whereas 10% had a score of >15%. The overall 30-day and 90-day mortality rates for our cohort was 0%, compared with 0% and 3% respectively in 2020-21.

Conclusion

Our data suggests that our clinic has enhanced equity of access to curative colorectal cancer surgery for older adults. 90 days mortality remained 0% owing to excellent patient selection and enhanced perioperative care. Importantly, 27% of patients declined surgery after an extensive process of SDM. Further work needs to be completed assessing decision regret and satisfaction with SDM (SDMQ9).
1657 RELATIONSHIP BETWEEN DELIRIUM AND CO-MORBIDITY IN ACUTELY HOSPITALISED OLDER MEDICAL PATIENTS
Authors: Atia N , Iyida O , Abdelmageed A , Knight S , Dijkstra A , Murfitt J , Onn L V , Obiechina N , Mukherjee B , Nandi A
Published: July 2023

Introduction

Delirium is common in hospitalised 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 aim of the study is to assess the correlation between delirium and co-morbidity in older medical inpatients. It also aims 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 in these patients (r=.236; p<.001). This effect was stronger in male than female patients (r=.275; p=.002) and (r=.197; p=.035) respectively.

Conclusion

There was positive correlation between comorbidity and delirium in this cohort of patients. The association appeared to be stronger in male than female patients. More studies are needed to explore and validate these findings.
1515 EVALUATION OF OUTCOMES ACROSS DELIRIUM SUBTYPES IN HOSPITAL ADMISSIONS IN PATIENTS WITH PARKINSON’S DISEASE
Authors: Rowley M , Kobylecki C , Thomson A
Published: July 2023

Introduction

Delirium is prevalent in patients with idiopathic Parkinson’s disease (iPD) who are admitted to hospital. The hypoactive subtype of delirium is associated with poorer outcomes in hospitalised patients. The aim of this study was to evaluate different outcomes across delirium subtypes in unplanned hospital admissions in patients living with iPD.

Methods

Data was collated prospectively on all patients with idiopathic Parkinson’s disease admitted to our hospital’s medical wards between 1st January 2019 and 30th March 2020. Electronic case-note review and in-person assessments were used to determine a diagnosis of delirium, the delirium subtype, and key outcomes including length of stay (LOS) and mortality. Data was analysed with respect to both index admissions and those readmitted during the study period.

Results

123 patients with iPD (male 52.8 %, mean age 77.9 years) accounted for 189 admissions. Delirium was present in 91/189 admissions (48%). There was no difference in Hoen & Yahr or Clinical Frailty Scale levels between groups with and without delirium. The prevalence of dementia was higher in the delirium group (48.3% vs 25.5%). Hypoactive delirium was the most common subtype (49.5%); hyperactive (13.2%), mixed (11%) and neutral (neither hypo- nor hyperactive) 26.4%. 12-month mortality in the index admissions was highest in the hypoactive subtype (57.1%). Median LOS (all admissions) was 11.5 days in patients with delirium vs 5.5 days in those without. A mixed delirium phenotype had longest LOS (mean 30.7 days) compared with other subtypes.

Conclusions

The hypoactive subtype of delirium predominates in hospitalised patients with iPD. Length of stay was longest in those experiencing a mixture of hyperactive and hypoactive subtypes, and mortality was highest in the hypoactive group. Healthcare settings need robust systems screening for delirium in Parkinson’s patients, with prevention and management processes to reduce morbidity and mortality in this complex group.
1644 FRAILTY AND OUTCOMES AFTER STROKE: A SYSTEMATIC REVIEW AND META-ANALYSIS
Authors: Elliott A , Kadicheeni M , Chin K , Divall P , Robinson T , Beishon L
Published: July 2023

Introduction

Frailty is an important clinical syndrome of increased vulnerability to stressors. The impact of frailty on stroke is a growing research area. We carried out a systematic review for an up-to-date picture of the prevalence of frailty and its impact on a wide range of outcomes.

Methods

We searched Medline, Embase and CINAHL for studies referencing frailty and stroke. We assessed quality of studies using National Heart, Lung, and Blood Institute (NHLBI) quality assessment tools. We collated prevalence of frailty and impact on outcomes after stroke or transient ischaemic attack (TIA). Meta-analysis was conducted to determine pooled odds ratios (OR) and 95% confidence intervals (CI). Where possible, we carried out metanalysis on outcome data.

Results

We included 28 studies (n=111,787). Studies used the Clinical frailty scale (CFS), (n=6, 10,967). a frailty index (n=10, 19134), Hospital Frailty Risk Score (HFRS) (n=4, 18,373), frailty phenotype (n=4, 10,838), or other assessment methods (n=8, 50,568). Pooled prevalence of frailty was 36% (95% CI 29-43%). Including pre-frailty, prevalence was 48% (40-56%). Increased CFS (n=738) was associated with increased in-hospital mortality, OR=2.43 (95% (CI 1.54-3.84). Higher frailty was associated with higher 28-day, 90 day and one year mortality, higher stroke severity, and NIHSS, mRS and dependency on discharge.

Conclusion

Increased frailty is associated with multiple adverse outcomes following a stroke, including mortality, worsened functional outcome, and increased dependency at discharge. There was heterogeneity in frailty measures used, precluding meta-analysis.
Do Taxes Affect Marriage? Lessons from History
Authors: Fox Edward
Published: July 2023

I examine how income taxes affected individuals’ marriage decisions in the mid-twentieth century using variations across U.S. states arising from the Revenue Act of 1948. Prior to the Act, the federal income tax produced marriage “bonuses” in some states, but marriage was tax neutral in the rest of the states. The Act extended the same marriage bonuses to the remaining states, without changing the regime in those states already enjoying bonuses. I use a difference-in-difference design to analyze the effect of the Act. I enrich the framework with an additional control group: lower-income Americans. For this group, marriage was income tax neutral throughout the period in every state. Using this additional control group, I employ a triple-difference design. In both the difference-in-difference and triple-difference designs, I find that extending marriage bonuses increased marriage rates among eligible men substantially.
Measurements of airborne asbestos fibres during refurbishing
Authors: Ervik Torunn Kringlen , Hammer Stine Eriksen , Skaugset Nils Petter , Graff Pål
Published: July 2023

Although the use of asbestos fibres in building materials has been prohibited in Norway since 1985, asbestos-containing materials (ACMs) are still found in many buildings. Lack of knowledge and awareness of these materials may lead to exposure during refurbishing. The aim of this study was to investigate the airborne fibre concentration and classify fibres found during the abatement of various ACMs. The release of fibres during short-term work tasks, such as drilling and sawing, was also investigated. Parallel air samples were collected during asbestos abetment of different building materials and analysed with scanning electron microscope (SEM) and phase-contrast microscope (PCM), respectively. Material samples were analysed with SEM. A real-time fibre monitor was used to measure asbestos during short-term work. The highest fibre concentrations were measured for samples collected during the removal of asbestos insulating boards (1.5–4.5 fibres/cm3 [f/cm3]), and the numbers were relatively similar for SEM and PCM. A large difference in asbestos concentrations was found between SEM and PCM when analysing floor materials, which were probably caused by a high number of gypsum fibres that the PCM operator counted. Thin fibres (<0.2 µm in width) were included in the SEM count and constituted up to 50% of the total fibre concentration for the asbestos cement materials. The presence of other inorganic and organic fibres on these samples probably led to similar results between SEM and PCM. Short-term work led to peak concentrations above 30 f/cm3.
Persistence of second-line biologics in psoriasis after first-line biologic failure: a nationwide cohort study from the French health insurance database (SNDS)
Authors: Marcombes Clarisse , Penso Laetitia , Weill Alain , Dray-Spira Rosemary , Zureik Mahmoud , Sbidian Emilie
Published: July 2023

Background

Many biologics are available for psoriasis and have been compared in real-life studies based on their persistence (i.e. time between initiation and discontinuation). However, after first-line biologic failure, data are lacking on the choice of second-line biologic among the four available classes [tumour necrosis factor inhibitors (TNFi); interleukin (IL)-12/IL-23 inhibitor (IL-12/IL-23i); IL-17 inhibitors (IL-17i); and IL-23 inhibitors (IL-23i)].

Objectives

To compare the long-term persistence of available second-line biologics in psoriasis according to prior exposure.

Methods

This nationwide cohort study involved the administrative healthcare database of the French health insurance scheme linked to a hospital discharge database. Participants were adults with psoriasis, defined as having at least two prescriptions of a topical vitamin D derivative within a 2-year period, with initiation of a second-line biologic between 1 January 2015 and 31 December 2021. We included patients who initiated a second-line biologic directly after first-line discontinuation (i.e. without a ‘washout’ period). The end of follow-up was 30 June 2022. Discontinuation was defined as > 90 days without filling a prescription for the same treatment after the period covered by the previous prescription. Comparison of persistence by biologic class involved using propensity score-weighted Cox models (inverse probability treatment weighting) and adjustment of specific systemic nonbiologics (time-dependent variables).

Results

We included 8693 patients [mean (SD) age 50 (14) years; 50.5% male]; 2824 (32.5%) started TNFi, 1561 (18.0%) IL-12/IL-23i, 2707 (31.1%) IL-17i and 1601 (18.4%) IL-23i. Overall, 1- and 3-year persistence rates were 60% and 30%, respectively. After weighting and adjustment, persistence was longer with IL-12/IL-23i [weighted hazard ratio (HRw) 0.68, 95% confidence interval (CI) 0.62–0.76)], IL-17i (HRw 0.70, 95% CI 0.64–0.78) and IL-23i (HRw 0.36, 95% CI 0.31–0.42) than TNFi, except after first-line IL-17i treatment, with no difference between IL-12/IL-23i, IL-17i and TNFi second-line persistence. Persistence was longer with IL-23i as a second-line treatment than IL-12/IL-23i (HRw 0.53, 95% CI 0.44–0.63) and IL-17i (HRw 0.51, 95% CI 0.44–0.60), regardless of first-line treatment, with no difference seen between IL-12/IL-23i and IL-17i (HRw 0.97, 95% CI 0.87–1.09).

Conclusions

This real-life study suggests the longer persistence of IL-23i than TNFi, IL-17i and IL-12/IL-23i as second-line treatment for psoriasis. Persistence rates for all biologics remained low at 3 years.