bluuebunny/crossref_metadata_2025 huggingface dataset:
472 A PILOT COLORECTAL AND GERIATRIC MEDICINE (CGM) CLINIC FOR OLDER, FRAIL PATIENTS REFERRED VIA A 2 WEEK WAIT PATHWAY
Authors: Thomas M , Cookson K , Clark R , Pearce L , Fox J , Price A
Published: June 2021

Introduction

The two week wait (2ww) colorectal referral pathway was introduced to expedite referrals where cancer is suspected, facilitating prompt diagnosis +/− intervention. Older frail patients are referred via this 2ww pathway even when invasive testing and intervention may not be appropriate. These patients may benefit more from holistic assessment than a universally surgical approach. A Colorectal and Geriatric Medicine (CGM) 2ww referral clinic was piloted, delivered by an urgent referral colorectal specialist nurse and an advanced clinical practitioner in geriatric medicine.

Method

Patients >65 years with a Clinical Frailty Scale (CFS) score of 5 or more at referral were directed to the CGM clinic. A telephone consultation was undertaken, incorporating both 2ww assessment and aspects of comprehensive geriatric assessment.

Results

42-patients were reviewed in the clinic. Mean age was 86.1 years and mean CFS 6. 12-patients underwent CT, and 2 CT virtual colonoscopy. No patients underwent endoscopic investigation and 28-patients declined any investigation. Of those who underwent investigation, no cancers were identified. 1 patient was referred on for endosocpic mucosal resection of polyps. 5-patients had severe diverticular disease, which accounted for their symptoms. Medication recommendations were made for 30-patients, some of which led to symptom cessation. Onward referrals were made to a community geriatrician, diabetes and continence teams, and palliative care specialists. 9-patients were identified as meeting criteria for advance care planning. This was commenced during the consultation and communicated back to the referring clinician for further action.

Conclusion

Older, frail patients are often not able, nor wish to undergo, invasive investigations but should not be disadvantaged or delayed in their pathway. Further work is needed to determine the most appropriate referral pathway for this group of patients. Holistic assessment that leads to improvement in symptoms and future planning may not be achievable through a solely surgical assessment.
475 DEVELOPING A VIRTUAL CARE HOME SUPPORT FORUM DURING THE COVID-19 PANDEMIC
Authors: Ferrigan L , Hartley R , Hadley E , Steward L , Ngwenya S , Harmer J , Robinson A , Cosmos S , Wilkinson I , Tucker P , Flores A , Baker R
Published: June 2021

Introduction

COVID-19 has had a devastating effect on care homes, increasing both morbidity and mortality of residents and staff. Between 2 March and 12 June 2020, COVID-19 was the main cause of death in male care home residents (33.5%) and second for female (26.6%).1 By 1 May 2020, the death rate from all causes in care homes exceeded that in hospital (6,409 versus 6,397).2 Thus, care homes had to rapidly adapt to facilitate safe care of patients and staff.

Method

An expert outreach team visited a number of care homes in Surrey and Sussex to explore COVID-19 issues in care homes. Key themes were identified that informed topics for the Virtual Care Home Forum, where a series of virtual teaching, training and peer support sessions were hosted either live or on-demand, accessible for all care home staff.

Results

12 sessions were held with an average attendance of 25 people, predominantly care home managers and community healthcare professionals. Real time qualitative feedback was collected and an electronic survey was completed at the end of the series which showed 100% felt the sessions had improved their understanding of the topic, 100% felt the knowledge and skills obtained from the sessions would be useful in their job, 87.5% agreed the sessions would impact or change their practise and 100% felt more supported during the pandemic.

Conclusion

It has been an unprecedented year for the NHS, and the care home sector has suffered significantly. In order to provide the best level of care for patients and support for our community colleagues, we must work collaboratively, including provision of education and training. To ensure equal access for all, maintaining user-safety and compliance with government legislation, virtual webinars proved to be an excellent modality. We plan to continue providing training, teaching and support through this means in the future.
480 INFORMATION OVERKILL: IF THE WALLS ACROSS HOSPITALS WARDS COULD TALK
Authors: Wijayasiri P , Than H P , Munir M , Sahota O
Published: June 2021

Background

The walls across hospital wards are cluttered with posters, which, in some places, are peeling and staining with the years. Hospital management and well intention ward users dictate these displays, however their effectiveness in delivering essential information is rarely measured. We undertook a survey to establish: a) Whether posters are effective, b) What information ward users want, c) How they want information to be delivered.

Methods

100 participants (68 staff and 32 patients’ relatives) were surveyed across three 28 bedded wards for older people. They had to recall as many posters as possible then identify useful posters from a current list. They were asked about unmet information needs, other media that they would utilise and alternative uses for ward walls. Interventions were made on one ward based on initial findings: 1. An ‘Information for Relatives’ board was created, 2. A mural was installed. 20 relatives were asked to complete an anonymous form reviewing the board.

Results

Only 23% of participants were able to recall at least 3 posters. 34% could not find a single useful topic among the current posters. The most popular unmet information needs, among many, were ‘the discharge pathway’, ‘delirium’ and ‘falls’. Most participants said they would engage with alternative information media, suggesting leaflets, email and websites. A quarter felt walls should be for artwork, not posters. The ‘Information for Relatives’ board was well received. In the second survey, new unmet information needs were uncovered and, despite the new mural, 45% called for more paintings still.

Conclusions

Most people do not read the information on the walls on hospital wards. An appetite exists for alternative media. Paintings were earnestly called for at every point; a comforting ward environment should be part of the holistic care we aim to offer, especially for older patients.
520 AN EVALUATION OF VIRTUAL MUSIC THERAPY TO PATIENTS ON AN ACUTE HEALTH CARE OF OLDER PEOPLE WARD DURING THE COVID-19 PANDEMIC
Authors: McAulay J , Block M , Booth V , Cowley A
Published: June 2021

Introduction

Music therapy has been shown to reduce anxiety and social isolation for elderly patients in the acute hospital setting. At Nottingham University Hospital NHS Trust a programme of live, face-to-face music has been delivered by Wellspring Music on Healthcare of Older Peoples wards since 2015. In response to COVID-19, face-to-face delivery was stopped and a virtual method was proposed. This project investigated feasibility of virtual live music delivery.

Method

Twelve, two-hour music therapy sessions were delivered by Wellspring Music to 41 patients over six weeks. The validated Arts-obs tool was used by staff members facilitating the sessions to record observations of patient mood, relaxation, and distraction from the ward setting on Likert scales. Patient, ward staff, and facilitator feedback were also recorded. Qualitative and quantitative analyses were conducted by an Occupational Therapist.

Results

Data from the Arts-obs tool showed that thirty-two patients had an observable improvement in mood, seven had no mood change, and two presented a slightly worsened mood. Fourteen patients were fully engaged with the music therapy, sixteen were partially engaged, and eleven were focussed on the hospital environment. Thirty-four patients were visibly more relaxed, and seven showed no change. Patient feedback ranged from gratitude and expressions of enjoyment of the session to finding it too loud. Ward staff feedback ranged from appreciation to finding the music too distracting. The Wellspring musician and staff facilitators reported occasional loss of internet connection, and patients sometimes focusing on the facilitator rather than the musician.

Conclusion

It is feasible to deliver virtual music therapy to inpatients on Health Care of Older People wards. Feedback shows that this was largely acceptable to staff and patients. Improvements in mood, relaxation and distraction were found.
528 EVALUATING THE PRESCRIPTION OF OPIATES IN PATIENTS WITH NECK OF FEMUR FRACTURES IN OUT OF HOSPITAL AND EMERGENCY CARE SETTING
Authors: Kanabar S , Mistry D , Naeem H , Smith R , Zahir F , Kumar A , Gurung Y K , Chatterjee A
Published: June 2021

Introduction

Opiate based analgesia forms a key component of Hip Fracture management. If prescribed inappropriately, opiate based analgesia can lead to respiratory depression, nephrotoxicity, and delayed recovery. The aim of this project was to evaluate opiate prescription in NOF patients in both out of hospital (OOH) and Emergency Department (ED).

Methods

100 consecutive patients were identified from National Hip Fracture Database between January and August 2019. Medical records were reviewed in both care settings, reviewing dose of morphine in comparison to body weight and renal function. Outcomes measured include constipation, acute kidney injury, respiratory compromise, and mortality. Statistical tests (t-test and chi square) were used to discern significance. Following the first cycle of results, results were disseminated to paramedics and at local governance meetings. Teaching was undertaken to increase awareness of harms associated with inappropriate opiate prescribing. A second cycle evaluated 30 consecutive NOFs from July 2020.

Results

In our study population, 74% were female and the average age was 84. The range of morphine doses given OOH ranged from 2-40 mg, in comparison to 2.5-20 mg in ED. 18% of patient suffered from Respiratory depression with 48 hours of their admission with a further 7% suffering from an acute kidney injury. After intervention, OOH morphine doses ranged between 5-10 mg, a reduction of 75% on maximum dose, with increased use of adjuvants as guided by the WHO pain ladder. No adverse outcomes were noted within 48 hours of admission.

Conclusion

Patient safety should be high on the agenda whilst caring for frail patients with Hip Fractures and opiate prescription is one of the most critical in the patient’s journey. Reducing harm by prescribing the optimal opiates helps to reduce mortality, morbidity, improve rehabilitation and patient flow within the NHS pathways. A guideline has been published to aid opiate prescription in elderly patients.
532 CARING FOR AND CARING ABOUT OLDER PEOPLE LIVING WITH SEVERE FRAILTY DURING COVID-19
Authors: Green R , King H , Nicholson C
Published: June 2021

Introduction

An ongoing study collected survey and interview data from older people with frailty living in the community near end-of-life during the Covid-19 pandemic.

Methods

Unstructured interviews with older people with frailty living in the community (N = 10), which included accounts from unpaid carers (N = 5), were video and audio recorded between October–November 2021. Six of these older people have died since fieldwork completion. A face-to-face survey collected data from a further 10 older people. Participants ages ranged from 70–99, 11, men, and 9 women, living in owned, rented, or sheltered accommodation, with Clinical Frailty Scores of 6 (N = 8), 7 (N = 9), and 8 (N = 3).

Results

Topics raised in relation to the pandemic included loss of social contact and increased loneliness, concern about not physically getting out, and losing physical function. Older people struggled to gain access to health and social care for support and previously received services were withdrawn. Most participants did not have access to internet and relied heavily on families to facilitate virtual contact with health professionals. Families and friends were the main anchor in facilitating social and health care including chasing up medications, liaising with social care to ensure quality and consistency of care provided, and monitoring older people’s health. Where older people’s conditions worsened family provided intense support, though family carers described the strain and unsustainability of this provision. Older people and their families felt they had been forgotten.

Conclusions

These are insights from hard-to-reach population that are frequently invisible. Greater examination of the impact of using communication technologies in care provision on those with poor access to and capabilities with using these technologies is required. Unpaid carers need more information and resources to support the care they provide and to facilitate access to appropriate social and health care services for those they care for.
546 QUALITY IMPROVEMENT PROJECT: IMPROVING CONTENT IN DISCHARGE SUMMARIES FOR CODING
Authors: Alcock C , Oluwamayowa P , Wallace E
Published: June 2021

Introduction

Hospital coding provides a pivotal service, integral to data collection, national statistics and hospital finances. The system of accurately coding depends almost entirely on the information put into Electronic Discharge Letters (EDLs). This project aims to up skill doctors with the expertise of the coding department, so that the EDLs reflect more accurately the experiences of the patient in hospital.

Method

Cycle 1; A member from the coding department was invited to the ward once a week to join with junior doctors writing their discharge letter. The coding from the discharge letters produced during this time were compared to those immediately prior to the coding department’s involvement. Cycle 2; The lead author and a member from the coding team took a sample of 12 notes from the Ambulatory Emergency Clinic (AEC), for patients presenting in January and February of 2020.

Results

Cycle 1; there was no significant difference in the number of co-morbidities or revenue gained from EDLs written with the support of the coding team compared to doctors writing ELDs independently Cycle 2; For 9 of the 12 patients (75%), co-morbidities were added. This changed the Healthcare Resource Group coded of 5 patients, resulting in an increasing the revenue to the hospital by £757 on average. For the number of patients seen in AEC in January, this could represent £218,271 of lost revenue, in addition to other benefits of accurate record keeping.

Conclusion

The role of the physician cannot increase indefinitely, and there is a wealth of knowledge and experience to be gained from our colleagues in the coding department. This collaboration in assiduously improving the service that our patients receive brings the possibility of large financial gains as well as more accurate health care records.
559 IDENTIFYING PATIENTS WITH MOOD DISORDER FOLLOWING ADMISSION WITH HIP FRACTURE WITH A VIEW TO STARTING TREATMENT & PROVIDE ADVICE
Authors: Giles K , Hall P , Wilson H , Macpherson L , Martin-Hernandez M P , Thompson K , Bailey S
Published: June 2021

Introduction

The signs of depression in the elderly often go unnoticed. The MDT at RSCH observed that low mood could negatively impact on patient’s recovery, affecting pain thresholds and leading to poor engagement with rehabilitation. Proactive identification and management of mood disorder is an important part of CGA, but not routinely performed. The aim of this QI project is to improve identification and management of mood disorder in patients over 65 years admitted to RSCH with hip fractures by introducing a standardised assessment tool to guide appropriate interventions.

Method

Notes of patients with hip fracture admitted over a four-month period were retrospectively reviewed to establish if patients were screened for low mood. A mood screening tool, Cornell Score, was chosen and implemented by OT’s and junior doctors over a four-month period. Those identified with depression or probable depression were issued verbal advice, an information leaflet and follow-up arranged.

Results

Ninety-eight patients were included in the retrospective cohort; There was no indication that mood was considered or assessed at any point during admission. During the four-month prospective period, 86 patients (96%) were screened for low mood; 9% had major depression and 16% probable depression. Feedback from our occupational therapists and doctors was positive, with the tool being easy to use in patients with or without cognitive impairment. Much of the assessment could be incorporated into initial assessment or in gaining collateral history. Anecdotally, considering patients psychological well-being had a positive impact on inpatient therapy sessions guided the MDT in supporting the patient appropriately.

Conclusion

Implementation of a standardised and validated mood screening tool enabled us to identify that a quarter (25%) of the patients had, or probably had depression. This allowed us to intervene with simple measures such as verbal advice and an information leaflet and consider pharmacological intervention where appropriate.
576 ESTABLISHING VIRTUAL MULTIDISCIPLINARY ROUND IN BELFAST TRUST NURSING HOMES: PHARMACIST, NURSING & HEALTHCARE TEAM COLLABORATION
Authors: Crawford P , Kirkpatrick F , Galway O , Watson K
Published: June 2021

Introduction

During the first covid surge, 25% of Belfast HSC Trust (BHSCT) care homes were affected, rising to 44% by surge 3, resulting in limited face to face access for healthcare professionals. Nursing home residents required medicine reviews post-covid infection to optimise medicines and reduce pill burden.

Method

The Care Home Nursing Support Team (CHNST), consultant pharmacist for older people and the lead care home pharmacist medicines optimisation older people (MOOP), rapidly established a multidisciplinary virtual round. Four main steps included:

An SOP was established to ensure consistent pathway for nursing home inclusion criteria and team roles. The inclusion group included residents who were furthest from their baseline including weight loss, swallowing difficulties, decreased mobility, altered sitting balance and polypharmacy.

The pharmacist developed a proforma template for completion by the nursing home staff to gather key information ahead of the round to improve efficiency eg swallow, renal function, pain, falls risk.

The care home resident was included on video link by ipad following careful consent processes. Benefits included enhanced assessment of frailty, mobility, dexterity and adherence.

Results

Conclusion

The multidisciplinary care home rounds provided an efficient means to collaborate with other professionals, while providing holistic & patient-focussed care. Plans are underway for development of an NI MOOP care home pathway.
471 LET’S TALK DEMENTIA
Authors: Ashraf M , Mahmood A , Honney K
Published: June 2021

Introduction

By 2021 over one million people will be living with dementia (1) costing the government an estimated £30bn a year (2). However, cognitive decline is often misdiagnosed or missed completely in hospital admissions, resulting in delays in detection and treatment for patients. Quick and simple screening tools such as the Abbreviated Mental Test Score (AMTS) could help provide early detection and faster treatment times for such patients. Data from Queen Elizabeth Hospital Kings Lynn showed that only 56.8% of patients over the age of 75 were being assessed for cognitive function on admission, while the national targets are set at 90%.

Methods

A multi-cycle, trust wide, quality improvement project was used to improve screening outcomes for dementia in QEHKL. A baseline measure of screening was taken by QEHKL coding department. Five PDSA (Plan Do Study Act) cycles were undertaken, implementing interventions to aid screening at each stage. Examples include improved medical clerking booklets, trust wide education and allocated ward ‘Dementia Champions’. Performance was assessed by auditors, through patient notes and discharge letters.

Results

Over a 4-month period, 432 patient notes were inspected on six medical wards. Results after interventions showed a significant rise in Dementia Screening from 58.7% to 89.8%. AMTS completion was 70.7% in September 2020 on medical wards which improved to 85.7% in November 2020. Results were collected during the COVID-19 pandemic however, COVID wards were excluded.

Conclusion

The QI project has highlighted that education and accessible tools can improve cognitive screening numbers. An important note is, due to increased pressures during the COVID pandemic it is plausible that screening rates were adversely affected. Despite this, our figures still show positive improvement. The next cycle of our project includes surgical wards and we expect by the time of presentation to have this data to show.
547 QUALITY IMPROVEMENT PROJECT IN PRESCRIBING THICKENERS POST STROKE
Authors: Abubacker S , Attia A , Alcock C
Published: June 2021

Introduction

One of the therapies that Speech and Language Therapy SALT) provide is a level to which fluids must be thickened to ensure a safe swallow. The thickening agent should be supplied by the hospital to the patient on discharge. This requires the thickening agent to be added to the electronic discharge letter (EDL) and, ‘To Take Out’ (TTO) medication list by ward doctors.

Method

samples of 10-20 EDLs, taken from SALT list of stroke patients between interventions. Cycle 1: SALT were initially attempting to contact the physicians responsible for writing the EDL Cycle 2: SALT kept a register of patients that they had seen the recommended thickener prescription. This list was kept in the doctor’s office. This list was mentioned in handover every morning for doctors to update EDL Cycle 3: The aforementioned list was continued, and responsibility for transfer onto EDLs was delegated to the on call Senior House Officer (SHO) Cycle 4: In addition to the above measures, custom made stickers were added to the prescription chart as an indicator to add thickener to the TTO.

Results

Cycle 1: 20% Prescribed (n = 10) Cycle 2: 78% Prescribed n = 18) Cycle 3: 93% Prescribed (n = 14) Cycle 4: 100% Prescribed (n = 10).

Conclusion

This project has built up a multidisciplinary system to a multidisciplinary problem. Through repeated cycles and system improvement, we have seen and demonstrated a collaborative effort resulting in consistent and improving results.
462 COUNSELLING IN CARE HOMES
Authors: Pybis J , Chigariro N , Bacon J
Published: June 2021

Introduction

Although many people live well within care homes, it is estimated that 60% of those living in residential care have poor mental health (Age Concern & Mental Health Foundation, 2006) and 40% suffer from depression (The Royal College of General Practitioners, 2014). Antidepressant prescribing has been reported to be nearly four times greater in care homes than for older people living in the community (Harris, Carey, Shah, Dewilde & Cook, 2012). However, antidepressants have been found to be ineffective for people with dementia (Dudas, Malouf, McCleery & Dening, 2018). With two-thirds of care home residents having some form of dementia, there is a need to find alternative interventions. Talking therapies, such as counselling, may be a useful alternative.

Method

Adopting a qualitative approach using semi-structured interviews and focus groups with counsellors (N = 12) who have experience of working in this context and with care home managers (N = 3) and care teams (N = 6), this study aimed to explore the feasibility of implementing counselling in a care home setting. We explored the views of care home staff towards counselling and identify barriers to service implementation, alongside the experience of counsellors who have delivered counselling in care homes to understand what service delivery models are currently adopted. Data were analysed thematically.

Results

Findings fell under the following key themes: The funding and referral process for counselling in a care home; skills and competences required; training needs; adaptations to practice; barriers to implementing counselling in a care home.

Conclusions

It is timely to consider the role of psychological therapy in supporting the mental health of care home residents. There is a need for further research to explore a service delivery model of counselling in care homes.
484 CHANGING PRACTICES OF DECISION MAKING REGARDING DO-NOT-ATTEMPT-CARDIOPULMONARY-RESUSCITATION ORDERS AMID THE COVID-19 PANDEMIC
Authors: Connellan D , Diffley K , McCabe J , Cotter A , McGinty T , Sheehan G , Ryan K , Cullen W , Lambert J , Callaly E , Kyne L
Published: June 2021

Introduction

The COVID-19 pandemic has brought the decision-making process regarding cardiopulmonary resuscitation into focus. This study aims to analyse Do-Not-Attempt CPR (DNACPR) documentation in older hospitalised patients before and during the COVID-19 pandemic.

Methods

This was a retrospective repeated cross-sectional study. Data including co-morbidities and resuscitation status was collected on 300 patients with COVID-19 hospitalised from March 1st to May 31 s t 2020. DNACPR documentation rates in patients aged ≥65 years with a diagnosis of COVID-19 were compared to those without COVID-19 admitted during the same period. Pre-COVID-19 pandemic DNACPR documentation rates were also examined. Factors associated with DNACPR order instatement during the first wave of the COVID-19 pandemic were identified.

Results

Of 300 COVID-19-positive patients, 28% had a DNACPR order documented during their admission. 50% of DNAR orders were recorded within 24 hours of a positive swab result for SARS-CoV-2. Of 131 patients aged 65 years or over within the cohort admitted with COVID-19, 60.3% had a DNACPR order compared to 25.4% of 130 patients ≥65 without COVID-19 (p < 0.0001). During a comparable time period pre-pandemic, 15.4% of 130 older patients had a DNACPR order in place (p < 0.0001). Independent associations with DNACPR order documentation included increasing age (Odds Ratio [O.R.] 1.12; 95% CI 1.05-1.21); nursing home resident status (O.R. 3.57; 95% CI 1.02-12.50); frailty (O.R. 3.34; 95% CI 1.16-9.61) and chronic renal impairment (O.R. 5.49; 1.34-22.47). The case-fatality-rate of older patients with COVID-19 was 29.8% versus 5.4% without COVID-19. Of older COVID-19-positive patients, 39.2% were referred to palliative care services and 70.2% survived.

Conclusion

The COVID-19 pandemic has prompted more widespread and earlier decision-making regarding resuscitation status. Although case-fatality-rates were higher for older hospitalised patients with COVID-19, many older patients survived the illness. Advance care planning should be prioritised in all patients and should remain clinical practice despite the pandemic.
527 FRAILTY AND MULTIMORBIDITY IN TYPE 2 DIABETES: A UK BIOBANK ANALYSIS
Authors: Hanlon P , Jani B D , Butterly E , Nicholl B , Lewsey J , McAllister D A , Mair F S
Published: June 2021

Introduction

Frailty and multimorbidity are common in type 2 diabetes (T2D), including people <65 years. Guidelines recommend adjustment of treatment targets in people with frailty or multimorbidity, however guidelines do not differentiate these two related states. It is unclear how recommendations to adjust treatment targets in people with frailty or multimorbidity should be applied to different ages. It is also not known if the relationship between HbA1c and outcomes is similar in people with and without frailty. We assess implications of frailty/multimorbidity in middle/older-aged people with T2D.

Methods

Analysis of UK Biobank participants (n = 20,566) with T2D aged 40-72 years comparing two frailty measures (frailty phenotype and frailty index) and two multimorbidity measures (Charlson comorbidity index and a simply count of 40 long-term conditions (LTCs)). Outomes: mortality (all-cause, cardiovascular- and cancer-related mortality), Major Adverse Cardiovascular Event (MACE), hospitalization with hypoglycaemia or fall/fracture.

Results

Measure choice influenced the population identified: 42% of participants were identified as frail/multimorbid by at least one measure; only 2.2% were identified by all four measures. Both frailty and multimorbidity, by all measures, were prevalent throughout the age range studied. Each measure was associated with mortality, MACE, hypoglycaemia and falls. The absolute 5-year mortality risk was higher in older versus younger participants with a given level of frailty (e.g. 1.9%, and 9.9% in men aged 45 and 65, respectively, using frailty phenotype) or multimorbidity (e.g. 1.3%, and 7.8% in men with 4 LTCs aged 45 and 65, respectively). Using frailty phenotype, the relationship between higher HbA1c and mortality was stronger in frail compared with pre-frail or robust participants.

Conclusion

Assessment of frailty/multimorbidity should be embedded within routine management of middle-aged and older people with T2D. Method of identification as well as features such as age impact baseline risk and should influence clinical decisions (e.g. glycaemic control).
536 NEGOTIATING INDIVIDUALLY TAILORED URGENT CARE PLANS FOR OLDER PEOPLE IN AMBULATORY EMERGENCY CARE
Authors: Mckelvie S
Published: June 2021

Introduction

Ambulatory emergency care (AEC) provides hospital-equivalent medical care in out-of-hospital settings for acutely unwell complex older patients. This ethnography aimed to understand the cognitive work of the senior clinicians in the AEC environment.

Methods

Three AEC sites were purposively sampled to recruit twelve clinicians with backgrounds in Geriatrics, General Practice, Emergency and Acute Medicine. This qualitative investigation used focused ethnography within a case study approach to understand the decision-making processes in the context of the AEC environment. Participant-observation during an AEC shift was complemented by informant interviews. A framework approach to thematic analysis used a priori and data derived codes to develop explanatory themes. Ethnographic principles of constant comparison and cognitive task analysis were used to evaluate the clinicians’ decision-making processes for index patient cases.

Results

This ethnographic case study showed that AEC clinicians tailored their management plans to the individual patient based on their clinical assessment and needs, using creative problem solving and reflexivity. The AEC clinicians personalised their interventions based on the patient assessment, the patients’ wishes and disease severity. The individual tailoring of the AEC plan was negotiated with the patient, their next-of-kin and the multidisciplinary team (MDT). The discussions with patient and families allowed discussion of the differing priorities and facilitated compromise. AEC plans were also negotiated with the MDT to build a shared understanding of the patients’ needs. The MDT also provided cognitive and emotional support by challenging and validating the senior decision-makers clinical plans.

Conclusion

This tailored approach allowed the flexible delivery of AEC to meet the patients’ needs. It is hoped that by characterising the work of AEC clinician that this study will aid the development of medical training curricula, interdisciplinary working and health service design. Further research is needed on team-based decision-making for individually tailored care in urgent care settings.
454 ASSOCIATION BETWEEN STATINS AND MAJOR ADVERSE CARDIAC EVENTS AMONG OLDER ADULTS WITH FRAILTY: A SYSTEMATIC REVIEW
Authors: Hale M , Zaman H , Mehdizadeh D , Todd O , Callaghan H , Gale C P , Clegg A
Published: June 2021

Background

Statins reduce the risk of major adverse cardiovascular events (MACE), however, their clinical benefit for primary and secondary prevention among older adults with frailty is uncertain. This review investigates whether statins prescribed for primary and secondary prevention are associated with reduced MACE among adults aged ≥65 years with frailty.

Methods

Systematic review of studies published between 01.01.1952 and 01.01.2019 in MEDLINE, Embase, Scopus, Web of Science, Cochrane Library and the International Pharmaceutical Abstracts. Studies that investigated the effect of statins on MACE among adults ≥65 years with a validated frailty assessment were included. Data were extracted from the papers as per a pre-published protocol, PROSPERO: CRD42019127486. Risk of bias was assessed using the Cochrane Risk of Bias in non-randomised studies of interventions.

Finding

18794 abstracts were identified for screening. From these, six cohort studies fulfilled the inclusion criteria. There were no randomised clinical trials. Of studies involving statins for primary and secondary prevention (n = 6), one found statins were associated with reduced mortality (hazard ratio (HR) 0.58, 95% confidence interval (CI) 0.37–0.93) and another found they were not (p = 0.73). One study of statins used for secondary prevention found they were associated with reduced mortality (HR 0.28, 95%CI 0.21–0.39). No studies investigated the effect of statins for primary prevention or the effect of statins on the frequency of MACE.

Discussion

This review summarizes the existing available evidence for decision making for statin prescribing for older adults with frailty. This study identified only observational evidence that, among older people with frailty, statins are associated with reduced mortality when prescribed for secondary prevention, and an absence of evidence evaluating statin therapy for primary prevention. The findings of this study highlight that randomised trial data are urgently needed to better inform the use of statins among older adults living with frailty.
488 GRIP STRENGTH FROM MIDLIFE AS AN INDICATOR OF LATER-LIFE COGNITION AND BRAIN HEALTH: EVIDENCE FROM A BRITISH BIRTH COHORT
Authors: Dercon Q , Nicholas J , James S-N , Schott J , Richards M
Published: June 2021

Introduction

Grip strength is an objective measure of physical function with potential predictive value for health in ageing populations. We aimed to assess whether levels and changes in grip strength from midlife predicted later-life brain health and cognition.

Methods

446 participants in an ongoing British birth cohort study, the MRC National Survey of Health and Development (NSHD), had their maximum grip strength measured at ages 53, 60–64, and 69, and underwent neuroimaging as part of its neuroscience sub-study, Insight 46, at 69–71. A group-based trajectory model identified latent groups of individuals in the whole NSHD cohort with below- and above-average grip strength over time, plus a reference group. Trajectory group membership, plus standardised grip strength levels and change from age 53, were each related to MRI-derived measures of whole-brain volume (WBV) and white-matter hyperintensity volume (WMHV), plus several cognitive tests. Models were adjusted for sex, body size, head size (where appropriate), sociodemographics, and behavioural and vascular risk factors.

Results

Consistently below-average grip strength from midlife was associated with lower WBV and non-verbal reasoning ability at age 69–71 (e.g. low group WBV vs. reference group β = −13.38 cm^3; 95% CI = (−24.12 cm^3, −2.64 cm^3); p = 0.015). There was some accompanying evidence that above-average maximum grip strength showed a positive association with WBV, which was more pronounced in female participants (high group female WBV vs. reference group β = 18.30 cm^3; 95% CI = (1.34 cm^3, 35.29 cm^3); p = 0.034). Steeper than average declines in grip strength between 53 and 69 were additionally weakly associated with an estimated 10% higher WMHV at age 69–71 (β = 1.10, 95% CI = (1.00, 1.22); p = 0.053).

Conclusion

This study provides preliminary evidence that tests of maximum grip strength may have value in predicting brain health. Future work should assess how these observed differences relate to later-life negative health outcomes, and whether changes in grip strength reflect concurrent changes in brain structure and connectivity.
495 CONVERSATIONS ON LIVING & DYING: AN INTERVENTION TO INCREASE COGNITIVELY-ABLE, COMMUNITY-BASED FRAIL ELDERS’ ENGAGEMENT WITH ACP
Authors: Combes S , Gillett K , Norton C , Nicholson C J
Published: June 2021

Introduction

Advance care planning (ACP) can support person-centred end-of-life care by helping individuals articulate their end-of-life preferences. Frail elders’ vulnerability to deterioration makes ACP engagement particularly relevant; however, their engagement with ACP is uncommon. This study aimed to develop an intervention to increase ACP engagement with cognitively-able, community-dwelling frail elders.

Methods

Multiple methods were used to establish ACP barriers and facilitators: a systematic integrative review, modified e-Delphi survey (multidisciplinary health and social care professionals (H&SCPs) n = 73), and semi-structured interviews (frail elders n = 10, family members n = 8). A conceptual model, developed from the integrative review, underpinned data collection for the e-Delphi and interviews. Triangulation, including patient and public involvement, was then used to identify H&SCPs behaviours that needed to change and decide intervention content and implementation. The intervention was developed using behavioural change theory. Prototype refinement consisted of pre and post questionnaires, use of the intervention in practice, and focus groups (H&SCPs n = 26).

Results

The prototype intervention consists of a 3.5-hour training and education session for H&SCPs, supported by a toolkit. The intervention focuses on the relevance and experience of ACP for frail elders and ACP strategies H&SCP can use to encourage frail elders’ ACP engagement. Strategies include recognising the importance of decision-making in relationships and living well now, starting early, using an honest but gentle approach, and helping frail elders prepare for ACP conversations. Participants report that the intervention helps them think differently about ACP and encourages them to engage frail elders with ACP.

Conclusions

To our knowledge this is the first intervention underpinned by behaviour theory that focuses on supporting H&SCPs to engage community-dwelling, cognitively-able frail elders with ACP. Refinements, such as additions to the toolkit, have been suggested. However, H&SCPs appear to find the intervention acceptable, feasible, engaging, and useful in their practice.
496 NON-RANDOMISED FEASIBILITY STUDY OF THE REHABILITATION POTENTIAL ASSESSMENT TOOL (REPAT) IN FRAIL OLDER PEOPLE IN ACUTE SETTING
Authors: Cowley A , Goldberg S E , Gordon A L , Logan P A
Published: June 2021

Introduction

Clinicians are often required to decide about patients’ potential to respond to rehabilitation. ‘Rehabilitation potential’ can determine what services patients can access. In acute hospitals clinicians have limited time to assess and deliver rehabilitation which takes into account the complexities of frailty and ageing. We set out to evaluate whether the Rehabilitation Potential Assessment Tool (RePAT)—a 15 item assessment tool and training package which emphasises person-centred approaches—was feasible and could aid rehabilitation decisions.

Method

A non-randomised feasibility study with nested semi-structured interviews, set in the acute hospital, explored whether RePAT was deliverable and acceptable to staff, patient and carers. A maximum variation sample of physiotherapists and occupational therapists was recruited. Patient and carer participants were recruited from Healthcare of Older People wards. Staff and patient characteristics were summarised using descriptive statistics. Interview data were analysed thematically. Fidelity of completed RePAT items was assessed on how closely they matched tool guidance by two reviewers. Mean values of the two scores were calculated.

Results

Six staff participants were recruited and trained, and assessed a total of 26 patient participants using RePAT. Mean patient age was 86.16 (±6.39) years. 32% were vulnerable or mildly frail, 42% moderately frail and 26% severely or very severely frail using the Clinical Frailty Scale. Mean time to complete RePAT was 32.7 (±9.6) minutes. 13 out of 15 RePAT items achieved fidelity. RePAT was acceptable and tolerated by staff and patients. Staff participants reported RePAT enabled them to consider the complex and dynamic nature of rehabilitation decisions in a more structured and consistent way.

Conclusion

RePAT was found to be acceptable and tolerated by staff, carers and patients. It allowed clinicians to make explicit their reasoning behind rehabilitation potential decision-making and encouraged them to become more cognisant of ethical dilemmas and biases.
501 DISCHARGE AFTER HIP FRACTURE SURGERY IN RELATION TO MOBILISATION TIMING BY PATIENT CHARACTERISTICS: A NATIONAL DATABASE STUDY
Authors: Sheehan K J , Goubar A , Martin F C , Potter C , Jones G D , Sackley C , Ayis S
Published: June 2021

Introduction

Early mobilisation leads to a two-fold increase in the odds of discharge by 30-days compared to late mobilisation. Whether this association varies by identified reasons for delayed mobilisation is unknown.

Methods

Audit data linked to hospitalisation records for patients 60 years or older surgically treated for hip fracture in England/Wales 2014–2016. Adjusted proportional odds regression models tested whether the cumulative incidences of discharge differed for early compared with late mobilisation across subgroups defined by dementia, delirium, hypotension, prefracture ambulation and residence, accounting for competing risk of death.

Results

Overall, 34,253 patients presented with dementia, 9,818 with delirium, and 10,123 with hypotension. Prefracture, 100,983 were ambulant outdoors, 30,834 were ambulant indoors only, 107,144 were admitted from home, and 23,588 from residential care. 10%, 8%, 8%, 12%, and 12% fewer patients with dementia, delirium, hypotension, ambulant indoors only prefracture, or from residential care mobilised early compared to those without dementia, delirium, hypotension, with outdoor ambulation prefracture, or from home. Adjusted odds ratios of discharge by 30-days for early compared with late mobilisation were 1.71 (95% CI 1.62–1.81) for those with dementia, 2.06 (95% CI 1.98–2.15) without dementia, 1.56 (95% CI 1.41–1.73) with delirium, 2.00 (95% CI 1.93–2.07) without delirium, 1.83 (95% CI, 1.66–2.02) with hypotension, 1.95 (95% CI, 1.89–2.02) without hypotension, 2.00 (95% CI 1.92–2.08) with outdoor ambulation prefracture, 1.80 (95% CI 1.70–1.91) with indoor ambulation only prefracture, 2.30 (95% CI 2.19–2.41) from home, and 1.64 (95% CI 1.51–1.77) from residential care.

Conclusion

Irrespective of dementia, delirium, hypotension, prefracture ambulation or residence, early compared to late mobilisation increased the likelihood of discharge by 30-days. Fewer patients with these conditions, poorer prefracture ambulation, or from residential care mobilised early. There is a need reduce this care gap by ensuring sufficient resource to enable all patients to benefit from early mobilisation.
509 POTENTIALLY INAPPROPRIATE MEDICATION USE AND MORTALITY IN PATIENTS WITH COGNITIVE IMPAIRMENT
Authors: Buckley E , Jonsson A , Flood Z , Lavelle M , O’Sullivan N , Nurdin N , Dowling P , Duggan E , McCreevey C , Duggan J , Kyne L , McCabe J J
Published: June 2021

Introduction

Potentially inappropriate medications (PIMsare associated with falls, hospitalisation, and cognitive decline. Few studies have investigated the association between PIMsrelated to cognitive impairment (PIMCog) and mortality in dementia or mild cognitive impairment (MCI).

Methods

This was a retrospective observational study. Patients diagnosed with MCI or dementia (DSM-IV criteria) presenting to a tertiary-referral memory clinic from 2013–2019 were eligible. The primary outcome was all-cause death. Secondary outcomes were vascular death and non-vascular death defined according to formal certification. The primary exposure variable of interest was PIMCog, defined as any medication in the Beers 2015 or STOPP criteria, classified as potentially inappropriate for patients with cognitive impairment. Anticholinergic burden was measured using the anticholinergic cognitive burden (ACB) scale. Polypharmacy was defined as ≥5 medications. Cox proportional hazard models were used to calculate hazard ratios (HRs) and 95% confidence intervals (95% CIs).

Results

There were 418 patients included (n = 261 dementia, n = 157 MCI). The median age was 79 (interquartile range {IQR} 74–82) and median follow-up was 809 days (IQR 552–1,571). One or more PIMCog was prescribed in 141 patients (33.4%). PIMCog use was associated with all-cause mortality after adjustment for age, sex, dementia severity, Charlson Co-morbidity Index, chronic obstructive pulmonary disease, congestive cardiac failure, and peripheral vascular disease. (HR 1.96, 95% CI 1.24–3.09). PIMCog use was associated with vascular death (HR 3.28, 95% CI 1.51–7.11) but not with non-vascular death (HR 1.40 95% CI: 0.78–2.52). Neither an ACB ≥3 (HR 0.87, 95% CI: 0.46–1.64) or polypharmacy (HR 1.87, 95% CI: 0.67–5.24) were associated with death.

Conclusion

The burden of PIMCog use in patients with cognitive impairment is high. PIMCog use is independently associated with all-cause mortality and vascular death. This is a potential modifiable risk factor for death in patients with neurocognitive disorders. Further research is required to independently validate this finding.
436 POSTOPERATIVE SYSTOLIC HYPOTENSION IN FRACTURED NECK OF FEMUR PATIENTS
Authors: Jones R , Cook J , Cannon A
Published: June 2021

Introduction

Secondary analysis of outcomes after 11,085 hip fracture operations from the prospective UK Anaesthesia Sprint Audit of Practice (ASAP 2) found an association between reduced intraoperative systolic arterial pressure (SAP) and postoperative mortality at five and 30 days. We sought to determine the incidence of hypotension in the postoperative period, rather than just intraoperatively, in a small sample of patients with fractured neck of femur.

Method

We performed a retrospective review of the notes, electronic vital signs and electronic general practice records from 40 patients with fractured neck of femur. We identified the latest SAP performed at their general practice (if done within one year before admission). We noted the pre-operative baseline SAP reading from the ward as well as the lowest SAP during several time periods: the pre-operative period; the fracture surgery; the recovery room; and during each 24-h period postoperatively until the fifth postoperative day.

Results

A SAP recording from general practice within the previous year was only accessible in 21 (53%) of patients, but where it was accessible, it was within 20% of the immediate preoperative SAP in 14 (66%) of patients. The incidence of relative hypotension (< 80% preoperative SAP) was 54% in the operating theatre, 41% in the recovery room, 65% on the ward during the remainder of the first postoperative 24 h, 55% during postoperative day 2, 53% during day 3, 33% during day 4 and 41% during day 5.

Conclusions

Postoperative hypotension was common in our sample. In our analysis, the highest incidence was on the ward during the first 24 hours postoperatively. However, 41% of patients still had hypotension 5 days postoperatively.