bluuebunny/crossref_metadata_2025 huggingface dataset:
Presentation and Outcomes with First-Line Chemotherapy in Advanced Cholangiocarcinomas—A Relatively Rare Component of Biliary Tract Cancers in India
Authors: Bhargava Prabhat G. , Kumar Amit , Simha Vijai , Shah Minit , Patkar Shraddha , Goel Mahesh , Ostwal Vikas , Ramaswamy Anant
Published: June 2021

Background Biliary tract cancers (BTCs) are a rare group of cancers with limited data with respect to advanced unresectable cholangiocarcinoma (CCA).

Materials and Methods The study is a retrospective study of patients with advanced unresectable/metastatic CCA, who received first-line palliative chemotherapy (CT1) from January 2014 to March 2019 at the Tata Memorial Hospital, Mumbai. Baseline clinical characteristics, chemotherapeutic regimens, and toxicities were evaluated.

Results One hundred and forty patients satisfied criteria for evaluation. Median age of the entire cohort was 57 years (range: 32–80). There were 87 patients (62.1%) with intrahepatic CCA, 35 patients (25%) with perihilar CCA, and 14 patients (10%) with distal CCA. One hundred and twelve patients (80%) had metastatic disease at presentation. Commonest CT1 regimens were gemcitabine–cisplatin (GC) in 89 patients (63.5%) and gemcitabine–oxaliplatin (GO) in 34 patients (24.3%). Sixty-three patients (45%) received second-line chemotherapy. With a median follow-up of 27 months, median progression-free survival for the entire cohort was 7.56 months (95% confidence interval [CI]: 6.23–8.88), and median OS was 12.16 months (95% CI: 10.08–14.24). Common chemotherapy-related grade 3/4 side effects included vomiting in 25 patients (17.9%), diarrhea in 23 patients (16.4%), and thrombocytopenia in 22 patients (15.7%).

Conclusion The current study in advanced CCAs is the largest of its nature from India. The common regimens used as first line were GC and GO. Tolerance and overall survival appear similar to previously published data.
Post-cochlear implant surgery Alopecia Areata in ophiasis pattern
Authors: Dalton-Petillo Stephen , Volsky Peter
Published: June 2021

Background:

Alopecia Areata is a form of relapsing nonscarring hair loss, which is a poorly understood autoimmune phenomenon characterized by T-cell inflammation as a result of environmental and genetic factors.

Aims and Methods:

There are numerous types of alopecia areata, but in this article we describe a case of a patient with alopecia in the post-operative setting of bilateral cochlear implantation in an ophiasis pattern.

Results:

While the patient was lost to follow up and a biopsy could not be obtained for confirmation, the physical exam and clinical scenario point to a diagnosis of alopecia areata ophiasis.

Conclusions:

This autoimmune condition, especially in the ophiasis pattern, is quite rare and carries a rather variable clinical course and response rate to treatment. As genetic predisposition and environmental factors such as stress from surgery can contribute, it is likely a rare post-operative condition but one to keep in mind.
435 THE IMPACT OF COMPREHENSIVE GERIATRIC ASSESSMENT IN THE OUTCOMES OF OLDER ACUTE NEUROSURGICAL PATIENTS
Authors: Soutter L , Yordanov S , Uff C , Sivapathasuntharam D
Published: June 2021

Introduction

As the population ages, an increasing proportion of the neurosurgical caseload is comprised of older patients. This trend is reinforced by technical advances and anaesthetic considerations within the field, allowing a higher proportion of patients eligible for surgery. Comprehensive geriatric assessment (CGA) is the gold standard clinical approach for evaluating older patients. Peri-operative care of older people (POPS) has provided strong evidence that CGA services can result in fewer post-operative complications. However, this evidence stems largely from trauma and orthopaedic surgery. Currently, there is little evidence of the impact CGA has on older neurosurgical patients. The study aimed to investigate whether CGA for older neurosurgical patients improved outcomes such as thirty-day mortality and length of stay.

Methods

A control group was established by collecting retrospective data for all acute neurosurgical patients over the age of 65. This was then compared with an intervention group who received CGA in the form of regular geriatric consultant reviews. 49 patients were recruited into each group.

Results

Analysis showed that the interventional group had a significantly higher mean age and level of frailty. They also had more confirmed complications with a significant difference in the diagnosis of pneumonia (p = 0.05) and hyponatremia (p = 0.015). Despite this, the thirty-day mortality was lower and average length of stay was on average two days shorter compared to the control group, although this did not reach statistical significance (p = 0.701). The study showed that more patients who received a CGA were discharged home (p = 0.209).

Conclusion

Our findings suggest that CGA input for older neurosurgical patients improves outcomes and should be incorporated routinely into neurosurgical clinical pathways.
460 THE IMPACT OF THE BONE MDT: EXPLORING CHANGES IN BONE PROTECTION DECISIONS BETWEEN 2015 AND 2018
Authors: Brooks S , Harper A , Pack L , Wheatley T
Published: June 2021

Introduction

The Hip fracture Multidisciplinary metabolic bone Team (MDT) was developed in June 2016 as a collaboration between Orthogeriatricians and the Metabolic Bone Team. The objective was to improve the quality of bone protection treatment decisions. This audit aimed to assess the impact of the new MDT by reviewing treatment decisions prior to and post its introduction. Data collection and.

Methodology

Case notes were reviewed for admissions from September to October 2015 and from September to November 2018. For both time periods the inpatient list, discharge summary and blood tests were reviewed in order to collect data regarding demographics, type of surgery, co-morbidities, calcium and vitamin D levels, bone protection prior to admission and bone protection decisions at discharge.

Results

In 2015, 83% of patients were admitted with no form of bone protection. Around 6% of patients were admitted on a bisphosphonate and 36% were discharged on a bisphosphonate. Less than 2% of people received denosumab prior to their admission, with this number rising to 9.4% at discharge. In 2018, 77% of patients were admitted on no form of bone protection. 5.4% were admitted on a bisphosphonate rising to 16% on discharge. No patients were admitted on denosumab, but 27% were discharged having received it in hospital, or with a plan to receive it from their GP.

Conclusions

There was a fall in bisphosphonate use and a significant increase in the frequency of denosumab prescription after the introduction of the Bone MDT. This MDT facilitated better decision-making through access to the further specialist skills from the endocrinologist and specialist nurses. Individual case discussion enhanced the delivery of personalised medicine.
463 THE USE OF FERINJECT TO MANAGE IRON DEFICIENCY ANAEMIA IN PATIENTS WITH NECK OF FEMUR FRACTURES
Authors: Meakin O , Adejumo S
Published: June 2021

Introduction

Iron-deficiency anaemia is a condition that is regularly seen in patients admitted with neck of femur fractures (NOFF) and is associated with increased morbidity peri-operatively. Intravenous ferinject is a method of iron replacement that leads to a more rapid increase in haemoglobin than oral replacement, therefore is often more favourable in this patient group, leading to better patient outcomes.

Method

A quality improvement project was undertaken. An initial audit was conducted to analyse the demographic of patients with NOFF and to assess the current practice of the orthogeriatric team when managing iron deficiency anaemia. This reviewed NOFF patients admitted in July 2017. The indications and benefits of ferinject were distributed to the medical team, encouraging use clinically, and a further audit was performed 2 years later to compare outcomes and practice, reviewing patients with NOFF admitted July–September 2019.

Results

It was found that 87% of patients with NOFF are iron-deficient on admission, and that introducing the use of ferinject meant that 50% fewer blood transfusions were required. Additionally, it highlighted that those who received ferinject during their admission had a smaller range of discharge haemoglobin levels than those who did not. Finally, it was found that the use of ferinject did not affect the rates of readmission in the assessed patient cohort.

Conclusions

The introduction of the use of ferinject in NOFF patients with iron-deficiency anaemia leads to a reduction in the requirement of blood transfusions required and to a reduction of the range of discharge haemoglobin levels. Ferinject therefore aids in improved recovery of NOFF patients. It does not, however, appear to have any effect on readmission rates in this patient group. Further education is required amongst the orthogeriatric team about the indications and benefits of ferinject to ensure that all eligible patient receive ferinject, improving their recovery.
524 QUALITY IMPROVEMENT PROJECT: INCORPORATING COMPREHENSIVE GERIATRIC ASSESSMENT INTO COMMUNITY HOSPITAL CLERKING
Authors: Oates A
Published: June 2021

Elderly patients transferred to community hospitals often have complex medical, social, psychological, functional and pharmacological backgrounds that require careful assessment in order to create and deliver a high quality, patient-centred care plan. Unfortunately, time pressures experienced by staff in acute hospitals can make Comprehensive Geriatric Assessment (CGA) unfeasible for every patient. Moreover, junior members of the medical team may be unsure as to which aspects of a patient’s background and presentation constitute important elements of a CGA. Failure to recognise and document pertinent issues can lead to prolonged admissions, disjointed care and failed discharges.

Admission to a community hospital presents a convenient ‘checkpoint’ in the patient’s hospital journey at which to undertake a CGA. Recording the relevant information in an effective clerking proforma when the patient is admitted ensures that this information is displayed clearly and in a way that is accessible to all members of the multidisciplinary team. The pre-existing clerking proforma at Amersham Community Hospital omitted several important elements of CGA (such as examination of feet and gait, assessment of mood, FRAX-UK score, creation of a problem list etc.) The aim of this quality improvement project was to create a thorough, yet user-friendly and time-efficient clerking proforma which incorporated the important components of CGA.

Using BGS guidance and NICE quality standards, alongside suggestions from the medical team, the existing clerking proforma was adapted and reformed. After one month, feedback from the team was used to further improve the clerking proforma, ensuring that it was user-friendly, whilst meeting the standards set out by NICE and BGS. This was repeated as part of a second PDSA cycle.

The improved clerking proforma enables junior doctors to undertake a thorough and holistic assessment, promoting efficient detection of issues and the delivery of a higher quality of care.
525 EVERYONE NEEDS TO POOP: REDUCING CONSTIPATION IN THE ELDERLY INPATIENT POPULATION
Authors: Rollo-Walker J C R G
Published: June 2021

Introduction

Due to a variety of factors when elderly patients are admitted to hospital they can become constipated. This can impact the entire admission increasing morbidity and mortality for what is a treatable problem. The aim therefore was to assess how prevalent constipation was across the inpatient population; analyse if there were any common themes and implement interventions that might help solve these.

Method

Data was collected over 15 days across the department (up to 87 patients) using nursing handover sheets to review the date bowels had last been opened. Patients were classified as constipated if they had not opened their bowels for more than 3 days. On two days common themes in the constipated patients were reviewed and analysed. On average 27% of patients were constipated. The majority of these had been deemed ‘Medically Ready for Discharge’. They all had either no or only a reduced range of aperients prescribed. Stakeholders including patients, nursing staff, prescribers and Consultants were surveyed. First cycle intervention was to highlight those constipated at morning Multi-disciplinary Team (MDT) meetings to prompt medical review. Second cycle intervention: an e-prescribing bundle was designed to allow for simple prescription and for nurses to give aperients on an as required basis. A laxative prescribing guide sheet was also written to aid prescribers.

Results

Aim is to reduce constipation to less than 20% thereby reducing morbidity and mortality in inpatients. Highlighting patients at MDT had little effect partly as it was person dependent. Effect of prescribing bundle yet to be determined but received positively by stakeholders. Prescribing guide received positively by Consultants and junior prescribers.

Conclusions

Person dependent intervention was ineffective at reducing constipation highlighted by staff sickness due to Covid-19. A prescribing bundle is more system based. If used at admission hopefully will be effective and sustainable.
533 READMISSIONS TO GERIATRIC MEDICINE IN A DISTRICT GENERAL HOSPITAL, A THEMATIC ANALYSIS
Authors: Whiting R , Comerford R
Published: June 2021

Introduction

621 patients were readmitted within 30 days of discharge from our Geriatric Medicine department between October 2019 and March 2020. This project was undertaken to better understand whether some of these readmissions could be prevented.

Methods

Analysis showed a clear peak of 78 patients returning at day one post discharge, and a subsequent Pareto analysis revealed that nearly 80% of these were discharged from 2 locations, our frailty unit and MAU. This cohort became the focus of our review. With support from the Acute Frailty Network, a virtual structured case note review was undertaken by a multidisciplinary team including an independent Geriatrician. This considered the patient’s case, whether they were cared for by the right team in the right place, whether they were readmitted with a new diagnosis and whether any improvements in the discharge process or wider service could have prevented their readmission.

Results

The case note review process was halted early as clear recurring themes emerged. Firstly, feedback showed that all frail patients were identified early in the patient pathway, were cared for by the appropriate team and a CGA was commenced promptly. Secondly, whilst the majority of day one readmissions had a diagnosis of delirium, most were not diagnosed as such until their re-attendance, despite documented confusion. Failure to recognise this, treat their delirium, and plan for fluctuations in cognition upon discharge were found to contribute to a high readmission rate.

Conclusion

We found that delirium identification was a key factor in early readmissions to our service. We identified clear opportunities to strengthen and formalise delirium diagnoses, and better plan patient management and discharge plans as a result. A multidisciplinary quality improvement group looking at delirium has been initiated and has already achieved a statistically significant improvement in the use of 4AT, a delirium assessment tool.
573 DELIRIUM SCREENING QUALITY IMPROVEMENT PROJECT
Authors: Al-Alousi S , Khan A U , Laithwaite E
Published: June 2021

Introduction

Delirium is a common neuropsychiatric syndrome in patients over the age of 65 presenting to medical admissions units yet remains under-diagnosed despite significant associated mortality and morbidity. Our trust's delirium screening tool incorporates a four-step approach, with completion of validated 4AT test warranted in all those over 65 years of age admitted with increased confusion or social withdrawal. Our aim was to measure current uptake of this delirium screening and introduce measures to improve practice.

Method

We retrospectively collected data from medical records of patients on two Geriatric inpatient wards (42 patients) at the Leicester Royal Infirmary, to determine whether appropriate delirium screening was taking place for at-risk patients on admission. We then introduced two PDSA (plan, do, study, act) cycles: 1. teaching at departmental weekly educational meetings with sending electronic communications to all doctors in medicine highlighting importance of delirium screening; and 2. displaying posters on all admissions wards. A third cycle was planned involving visiting wards to raise awareness, however this was interrupted by the COVID pandemic.

Results

Initial baseline results showed only 5% (1 of 18) of at-risk patients were fully screened for delirium. Following our first intervention, this increased to 13% (3 of 23). Second intervention involving display of posters led to an increase to 44% (8 of 18) of at-risk patients being screened. Proportions of dementia were comparable across PDSA cycles.

Conclusions

Education, raising awareness, and display of reminder posters can improve delirium screening uptake of at-risk patients on admission to medical admission units, despite growing pressures associated with the COVID pandemic. Further interventions are planned to improve and maintain awareness and uptake of delirium screening.
601 IMPROVING DELIRIUM ASSESSMENT IN A DISTRICT GENERAL HOSPITAL
Authors: Finlow C , Azaden L , Abbott C
Published: June 2021

Introduction

Delirium affects a up to 20% of medical inpatients1. Patients in the high-risk category include those over 65, pre-existing cognitive impairment, current hip fracture and those with a serious illness 1,2.

Often delirium goes undetected but is often related to high morbidity and motility rates with complications of insitionalisation, increased risk of dementia, high risk of falls and prolonged hospital stays1,2, recognition is the first step to reducing these risks. NICE guidance suggests that those patients showing indicators of delirium should have a formal cognitive assessment and a tailor-made plan should be documented within 24 hours 2.

The detection of delirium can be sort using licensed tools including the 4AT score with the 4AT being the most sensitive, specific and practical1. Due to the ongoing risks of delirium, high risk patients on the Geriatric medicine firm and poor detection rate a quality improvement methodology was used to increase the rates of detection of delirium.

The aim to have 90% of Geriatric medicine patients screened within 24 h admission and within 24 h of arrival to COTE ward/first consultant ward round within 4 months.

Method

4 PDSA cycles were designed to trial changes including education of the Geriatric medicine team, lanyard cards, introduction of 4AT on the frailty proforma and a non-intervention cycle to see if these changes were sustained.

Data was collected from the care of the elderly ward not including outliers of 27 patients. Any formal cognitive assessment that was documented either on admission or on arrival to the ward was included. Not included was those patients who were assessed for delirium or change in cognition after first consultant ward round or after 24 h of being on the ward.

Results

The uptake of 4AT improved by 50% after education and the lanyard cards. This was largely as a shift away from other assessments rather than more cognitive assessments done overall.

During service redesign an Older Person’s Assessment Unit was formed with a Geriatrician based at the front door. This will improve the use of the 4AT for older patients admitted to hospital in the near future and is the subject of the next PDSA cycle.

Conclusion

Our journey to embed the 4AT is ongoing and we will continue to improve uptake using QI methodology.
535 ELF 2: DEFINING THE DENOMINATOR ELF STUDY GROUP
Authors: Price A , Mclennan E , Boyle J ,   on behalf of the ELF2 study group
Published: June 2021

Introduction

The collaborative UK Emergency Laparotomy and Frailty (ELF) study was one of the first to investigate the older adult population undergoing emergency surgery. Despite accounting for almost half of emergency laparotomies and many considered high-risk, there remains a paucity of research in this population. One undefined area is the older patient who presents with acute abdominal pathology treatable by laparotomy but who do not undergo surgery.

Aims

The primary aim is to estimate the 90-day mortality in older patients presenting with acute abdominal pathology potentially treatable by emergency laparotomy who do not undergo surgery (NoLap). The secondary aims are characterisation of this group, including frailty and sarcopenia with comparison to those older adults that have undergone emergency laparotomy (NELA and ELLSA). In addition, the decision-making process will be explored.

Method

Multicentre prospective cohort study via established research collaboratives (Welsh Barbers, SSRG, OPSOC). ELF 2 requires at least 47 centres, recruiting 700 patients for 3 months prospective data collection via REDCap of NoLap patients with the same NELA inclusion/exclusion criteria. This data will be compared with a matched cohort from NELA and ELLSA. ELF2 data collection includes demographics, co-morbidities, frailty and sarcopenia. Each patient will be followed up for 90-day and 1-year mortality. Heuristics behind the decision will be analysed.

Discussion

This trainee led collaborative project aims to improve understanding of the older adult population being considered for emergency laparotomy. With the ageing population being the dominant health users of the future, defining the denominator is essential for shared decision-making.
434 LOOK OUT! VISUAL ASSESSMENT TOOL: UTILITY IN OLDER PERSON’S MENTAL HEALTH CARE SETTINGS
Authors: Hussain S , Thavachelvi C , Ruiz-Mendoza E
Published: June 2021

Introduction

Patients on old age psychiatry wards are at high risk of falls. It has been shown that poor visual acuity significantly increases the risk of recurrent falls in the elderly. The National Audit of Inpatient Falls (NAIF) Report 2015 found that vision was poorly assessed. The Look Out! Visual assessment has been developed for patients over 65 to receive visual screening on admission to reduce the risk of falls. To date, there has been no research into the applicability of the Look Out! test in mental health settings. Our aims are two-fold: (i) To investigate how often vision is assessed for inpatients on old age psychiatry wards and (ii) To identify the challenges of visual assessment in a mental health care setting.

Methodology

Data was collected at a mental health unit with two wards dedicated to old age psychiatry patients. Data was collected for patients admitted from May 2020 to July 2020 and analysing qualitative and quantitative data.

Results

From the 30 patients reviewed, 27% of patients had ophthalmic history, such as glaucoma or cataracts, 23% of patients had a fall during admission, yet only 43% of patients had a Look Out! vision assessment completed and documented. 54% of patients who had a Look Out! Assessment were found to have an abnormality; of those with an abnormality detected on Look Out!, 57% were new presentations of an eye abnormality. On questionnaires, we found it more challenging to complete assessments of patients that were agitated or with advanced dementia but assessments were fully completed if more time was dedicated.

Conclusions

These findings demonstrate that the Look Out! test is applicable in mental health settings, helping to identify those with visual impairments and raising the need to complete the screening tool in all patients admitted to inpatient mental health facilities.
407 QUALITATIVE ASSESSMENT OF COGNITIVE TRAINING FOR PEOPLE LIVING WITH DEMENTIA: AN INDIVIDUALISED APPROACH IS NEEDED AUTHORS
Authors: Beishon L , Haunton V , Subramaniam H , Mukaetova-Ladinska E , Paneraia R , Robinson T , Evley R
Published: June 2021

Background

Cognitive training (CT) may be beneficial in mild cognitive impairment (MCI) and early dementia. However, few studies have qualitatively evaluated CT programmes in dementia. The aim of this analysis was to explore the benefits and barriers to a home-based computerised CT programme for healthy older adults, and people living with MCI or dementia.

Methods

This was a nested qualitative study within a larger feasibility randomised trial of CT. Participants underwent semi-structured interviews after 12 weeks of CT. Where possible, participants were interviewed with their carers. The interview schedule and analysis were underpinned by the health belief model. Interviews were audio-recorded, transcribed, open-coded, and categorised into themes. The analytical framework was developed, and themes were condensed under four major categories: benefits and efficacy, barriers, threat, and behaviour.

Results

37 participants underwent interviews (10 healthy older adults, 4 MCI, 5 dementia, 9 patient-carer dyads [2 MCI, 7 dementia]). CT was feasible and acceptable to participants. Benefits included: enjoyment, improved awareness, benchmarking cognitive function, reassurance of abilities, and giving back control. Barriers were more prevalent amongst those with dementia: problems with technology, frustration, conflict between patients and carers, apathy and lack of insight, anxiety or low mood, and lack of portability. Perceived risk susceptibility of dementia varied between participants. Healthy older adults and MCI perceived the severity of dementia risk as high, which was only partially mitigated by CT. Participants living with dementia valued a more individualised approach to training, accounting for baseline characteristics. For people living with dementia, maintenance was as valued as improvement of cognitive function.

Conclusions

CT was a feasible intervention for healthy older adults, and people living with dementia and MCI. Benefits were present, but the identified barriers need to be addressed for CT to be implemented successfully.
494 DISCOMFORT IN PEOPLE WITH DEMENTIA ADMITTED TO AN ACUTE GENERAL MEDICAL HOSPITAL: A HOSPITAL CROSS SECTIONAL STUDY OF PREVALENCE
Authors: Low R , West E , Sampson P L
Published: June 2021

Introduction

The acute hospital is a challenging place for a person with dementia whose ability to communicate discomfort and need is impaired. Their discomfort may go unnoticed due to insufficient staffing and time resources in this acute environment. Concerns have been raised about the consequences of these overlooked discomfort (e.g. distress and agitation), and hence how we can correctly identify their sources and severity. This study aimed to describe the source of discomfort and challenging behaviours in people with dementia (PwD) in UK acute hospital.

Method

A cross-sectional observational study of 49 patients with dementia admitted to a NHS acute hospital. Their discomfort was detected and its sources were identified (Sources of Discomfort Scale) during an hour observation when they were at rest and moved by staff. Their challenging behaviours were also recorded (Neuropsychiatric Inventory) through interviewing with the ward staff, as well as documentation of severity of dementia and presence of delirium.

Results

The overall prevalence of discomfort was 98%, with excessively sleepy or tired being the commonest; 39 (80%) participants experienced three or more type of discomfort. The commonest sources of discomfort were physical (e.g. constipation) and environmental (e.g. physically restrained), affecting up to 43 (88%) and 42 (83%) participants respectively. There was also evidence of an association between delirium and sleepiness or tiredness’s discomfort, meaning that PwD with delirium were nearly triply as likely to feel uncomfortable because of sleepiness or tiredness. Challenging behaviours affected over 80% of our participants, with agitation or aggression being the commonest. On average, these behaviours were moderately severe.

Conclusion

Discomfort and challenging behaviours were very common in PwD admitted to acute hospitals. Patients and staff would benefit from more accurate and frequent detection of discomfort by focusing on non-pain-related discomfort and using observational scales.
505 INTERLEUKIN-6, C-REACTIVE PROTEIN, FIBRINOGEN, AND RISK OF RECURRENCE AFTER ISCHEMIC STROKE: SYSTEMATIC REVIEW AND META-ANALYSIS
Authors: McCabe J J , O’Reilly E , Coveney S , Harbison J , Collins R , Healy L , McManus J , Mulcahy R , Moynihan B , Cassidy T , Hsu F , Worrall B , Murphy S , O’Donnell M , Kelly P J
Published: June 2021

Background

Recent randomised trials showed benefit for anti-inflammatory therapies in coronary disease but excluded stroke. The prognostic value of blood inflammatory markers after stroke is uncertain and guidelines do not recommend their routine measurement for risk stratification.

Methods

We performed a systematic review and meta-analysis of studies investigating the association of C-reactive protein (CRP), interleukin-6 (IL-6) and fibrinogen and risk of recurrent stroke or major vascular events (MVEs). We searched EMBASE and Ovid Medline until 10/1/19. Random-effects meta-analysis was performed for studies reporting comparable effect measures.

Results

Of 2,515 reports identified, 39 met eligibility criteria (IL-6, n = 10; CRP, n = 33; fibrinogen, n = 16). An association with recurrent stroke was reported in 12/26 studies (CRP), 2/11 (fibrinogen) and 3/6 (IL-6). On random-effects meta-analysis of comparable studies, CRP was associated with an increased risk of recurrent stroke [pooled hazard ratio (HR) per 1 standard-deviation (SD) increase in loge-CRP (1.14, 95% CI 1.06-1.22, p < 0.01)] and MVEs (pooled HR 1.21, CI 1.10-1.34, p < 0.01). Fibrinogen was also associated with recurrent stroke (HR 1.26, CI 1.07-1.47, p < 0.01) and MVEs (HR 1.31, 95% CI 1.15-1.49, p < 0.01). Trends were identified for IL-6 for recurrent stroke (HR per 1-SD increase 1.17, CI 0.97-1.41, p = 0.10) and MVEs (HR 1.22, CI 0.96-1.55, p = 0.10).

Conclusion

Despite evidence suggesting an association between inflammatory markers and post-stroke vascular recurrence, substantial methodological heterogeneity was apparent between studies. Individual-patient pooled analysis and standardisation of methods are needed to determine the prognostic role of blood inflammatory markers and to improve patient selection for randomised trials of inflammatory therapies.
530 INTERPRETATION OF HBA1C VALUES IN GERIATRIC PATIENTS WITH TYPE 2 DIABETES: LARGE DIVERGENCE BETWEEN CLINICAL PRACTICE GUIDELINES
Authors: Christiaens A , Boland B , Henrard S
Published: June 2021

Introduction

An individualised glycated haemoglobin (HbA1c) target according to the patients’ health status is central in the glycaemic management of geriatric people with type 2 diabetes (T2D) in order to avoid hypoglycaemic events through an appropriate management of the glucose-lowering therapy (GLT). Current clinical practice guidelines (CPGs) provide different recommendations for patients’ HbA1c targets. Using real-life data from geriatric patients, this study aimed at assessing the concordance in interpretation of HbA1c values according to three current major CPGs from the Diabetes Canada-2018 (DC18), the Endocrine Society-2019 (ES19) and the American Diabetes Association-2020 (ADA20).

Introduction

Retrospective study in consecutive older patients (≥75 years) with T2D admitted to a Belgian geriatric ward, with GLT before admission and HbA1c measurement during the hospital stay. Patients were classified into three categories of HbA1c values according to the CPGs recommendations: in-target HbA1c (appropriate-GLT), too-low HbA1c (GLT-overtreatment) and too-high HbA1c (GLT-undertreatment). Concordance of health status classifications and GLT categories between the three CPGs was assessed using Cohen’s and Fleiss’ κ, respectively.

Results

Of the 318 patients (median age 84 years, 54% women), one-third were in intermediate health and two-thirds in poor health (κ = 0.86; excellent concordance). According to the DC18, ES19 and ADA20 CPGs, HbA1c was in-target for respectively 46%, 25% and 82% of the patients, and too-low HbA1c (GLT-overtreatment) was present in 28%, 57% and 0% (κ = 0.36; low concordance).

Results

Patients’ HbA1c values are interpreted differently according to these major CPGs, mainly because of differences in their recommendations about HbA1c target individualisation and specifically the definition of a too-low HbA1c value. In clinical practice, these diverging interpretations regarding overtreatment may lead to unsafe GLT prescribing and thereby to hypoglycaemic events in this high-risk population.
534 ADVANCED COMMUNICATION SKILLS: TEACHING DURING A PANDEMIC
Authors: Pedersen A , Greenhalgh M , Tan M , Terry R , Royle C , Royles K
Published: June 2021

Introduction

In the first wave of the COVID-19 pandemic, it was recognised there would be an increased demand on clinicians to provide patients and relatives with bad news. The national ban on hospital visiting rapidly changed the way in which this news would be delivered. In recognition of these new challenges, our team sought to design a teaching course that could be implemented quickly and cost effectively, with the aim of improving clinician’s confidence around these difficult skills.

Methods

A teaching programme was created using senior geriatric and palliative care clinicians as simulated patients, open to any grade and speciality. Learners were required to break bad news (BBN) without any visual feedback, to simulate skills required when using the telephone. Surveys were collected to determine self–assessed confidence across four domains (Table 1) before, immediately after and 4–20 weeks after the course. Participants were asked to rank their confidence for each skill on a 5 point scale with 1 being very unsure and 5 being very confident.

Results

Pre-teaching scores showed an average of 3 (neither confident nor unsure) across all domains. After the course all domains improved, most notably around discussing end of life (EoL) care and discussing information over the phone.

Conclusion

This project has highlighted a lack of confidence across all skill levels when it comes to BBN. This confidence is easily improved by a short, cost-effective teaching course. It remains to be seen if this improved confidence translates to better communication with relatives.
548 FRAILTY ANALYSIS ACROSS POPULATIONS: THE USE OF THE HOSPITAL FRAILTY RISK SCORE IN SPECIALISED SERVICES USING NHS NATIONAL DATA
Authors: Imam T , Konstant-Hambling R , Fluck R , Hall N , Palmer J , Conroy S
Published: June 2021

Introduction

Frailty is increasingly used to risk stratify older people, but across specialised services there is no standardised approach. The aim of this study was to answer the question posed by NHS England to assess frailty could be measured and related to outcomes across Specialsed Services. The Hospital Frailty Risk Score (HFRS) was used and the data published in Age and Ageing in 2020.

Method

A retrospective cohort study was performed using the Secondary Uses Service (SUS) electronic database for people aged 75 or older admitted between April 2017 and March 2018. Based on HFRS, the populations were risk stratified into mild, moderate and severe frailty risk. The relationships with length of stay, readmission rate, mortality and some selected condition specific treatment complications were quantified using descriptive statistics.

Results

Frailty was differentially distributed across the specialties; around one-third had mild frailty; another third had moderate frailty and one-quarter severe frailty. Increasing frailty risk was associated with increased length of stay for the index admission, more days in hospital in the year following intervention and increased risk of dying in hospital. Severe frailty was a powerful discriminator of the risk of death; between 25 and 40% of those with severe frailty risk died at 30 months across all specialties.

Conclusions

This study demonstrates the first application of the HFRS to a national dataset to describe service outcomes and mortality for older people undergoing a range of specialised interventions. This information was used to identify those that might benefit from holistic assessment, aid prognostication, commissioning and service planning. It informed the promotion of quality improvement work in this area via the Specialised Clinical Frailty Network. By implementing the HFRS, changes in outcomes can be plotted across years to assess improvements, performance and benchmarking.
426 PREVALENCE OF, AND RISK FACTORS FOR, DEMENTIA IN ADULT OUTPATIENT REFERRALS TO A REGIONAL REFERRAL HOSPITAL IN ARUSHA, TANZANIA
Authors: Roe C , Safic S , Mwaipopo L , Dotchin C , Klaptocz J , Gray K , Joseph M , Walker R
Published: June 2021

Introduction

The global burden of dementia is increasing, with the greatest increase predicted to occur in sub-Saharan Africa (SSA). Despite this there are limited previous data on the prevalence of, and risk factors for, dementia in SSA. This study aimed to estimate the prevalence of dementia, and investigate its associations, in those aged 60 years and older attending the outpatient department of Mount Meru Hospital in northern Tanzania. This is the first hospital-based outpatient dementia prevalence and risk factors study to be conducted in an east African population.

Methods

This was a one-phase cross-sectional study. Adults aged 60 years and over attending medical outpatients were screened for dementia using The Identification and Intervention for Dementia in Elderly Africans cognitive screening tool. Those who scored ≤9 were clinically assessed using the DSM-IV criteria. Demographic, medical comorbidity and lifestyle information were collected during a clinical assessment.

Results

Prevalence of dementia was 5.0% (95% confidence interval: 3.7–6.3). Binary logistic regression found female sex (odds ratio (OR) = 2.778), having no formal education (OR = 6.088), quantity of alcohol consumption (units/week) (OR = 1.080), uncorrected visual impairment (OR = 4.260), body mass index <18.5 kg/m2 (OR = 6.588) and stroke (OR = 15.790 with wide 95% confidence interval (3.48–74.475)) to be significantly, independently associated with dementia.

Conclusions

The prevalence of dementia in this population is lower than previously reported community-based rates in Tanzania, and similar to those in high-income countries. This is the first time the association between uncorrected visual impairment and dementia has been reported in SSA. Other associations identified are in keeping with previous literature. Further research on the management of dementia and its risk factors, and the support and education of carers and patients in east African populations is required.
451 THE BEST MARKER FOR COGNITION—RELATIVE HANDGRIP STRENGTH, ASYMMETRY OR WEAKNESS?
Authors: Ho V , Chen C , Merchant R A
Published: June 2021

Introduction

Handgrip strength (HGS) is increasingly used to estimate overall muscle strength. Association between low HGS and cognitive decline has been well documented. Recently, McGrath’s team elucidated a new dimension of HGS asymmetry with important implications on physical and cognitive limitations. It is unclear if these effects can be generalised. The Asian working group for sarcopenia (AWGS) has called for ‘special considerations’ due to ‘anthropometric and cultural or lifestyle-related differences’6. Hence, we aim to investigate if HGS asymmetry is associated with cognition in Asians.

Methodology

We defined sarcopenia by AWGS consensus: HGS <28 kg for men; <18 kg for women. Asymmetry was HGS >10% stronger on either hand; relative HGS was HGS adjusted for BMI. Low cognitive function was defined as MMSE<26. We compared weakness alone, any HGS asymmetry or relative HGS alone and combination of weakness and HGS asymmetry or relative HGS asymmetry. Each model was adjusted for demographic characteristics, hand dominance, obesity, frailty, physical activity, depression and perceived health status.

Results

738 Asian subjects participated. Mean age 70.8 ± 0.2 years, 45.1% males, 82.5% Chinese. More than 50% have multimorbidity. 5.4% were frail. Mean BMI 24.4 ± 0.1 kg/m2. Mean HGS 22.6 ± 0.3. 93 (12.7%) had symmetrical HGS and not weak, 59 (7.8%) asymmetrical and not weak, 321 (43.6%) symmetrical and weak, 265 (35.9%) asymmetrical and weak. Mean MMSE scores for weakness alone, asymmetry alone and combined weakness and asymmetry are 26.6 ± 0.1, 26.8 ± 0.2 and 26.5 ± 0.2 respectively. HGS asymmetry alone was not associated with better cognitive function OR 0.66 (95%CI: 0.30–1.44). Combined asymmetry and weakness was non-significantly linked to worse cognition OR 2.14 (95%CI: 0.79–5.82). We found relative HGS to be protective for cognitive decline, OR 0.31 (95%CI: 0.12–0.78, p = 0.012).

Conclusion

Our study highlights the impact of ethnicity in sarcopenia research. Our population shows association of relative HGS with cognition. Further longitudinal studies are needed.
514 FRAILTY IN OSTEOARTHRITIS AND THE INFLUENCE OF CO-MORBIDITY
Authors: Cook M J , Verstappen S M M , Lunt M , O’Neill T W
Published: June 2021

Introduction

Risk factors for frailty, including low physical activity and chronic pain, are common among people with osteoarthritis. The aim of this analysis was to determine the association between osteoarthritis and frailty and to determine whether comorbidities interact additively with OA to increase the likelihood of frailty.

Methods

Men and women aged 40-69 years who contributed to the UK Biobank were analysed. Data about self-reported physician-diagnosed diseases was collected, as well physical measurements, including hand-grip strength. Frailty (robust, pre-frail, frail) was assessed using a modified frailty phenotype, comprising five components: low grip strength, slow walking speed, weight loss, low physical activity, and exhaustion. The association between osteoarthritis and the frailty phenotype was determined using negative binomial regression, adjusting for age, sex, body mass index, smoking status, and Townsend deprivation score. We calculated the attributable proportion of risk of frailty due to additive interaction between osteoarthritis and common co-morbidities (cardiovascular disease, diabetes, COPD, and depression).

Results

457,561 people were included, 35,884 (7.8%) had osteoarthritis. The adjusted relative risk ratio (95% CI) for pre-frailty and frailty (versus robust), respectively was higher among people with (versus without) osteoarthritis: 1.58 (1.54, 1.62) and 3.41 (3.26, 3.56). There was significant additive interaction between the presence of osteoarthritis and each of the co-morbidities considered in increasing risk of frailty, particularly diabetes (attributable proportion of risk due to additive interaction with osteoarthritis (95% CI)), 0.49 (0.42, 0.55), coronary heart disease 0.48 (0.41, 0.55), and depression 0.47 (0.41, 0.53).

Conclusions

Our results suggest that people with OA are at increased risk of pre-frailty and frailty. The mechanisms are not fully understood, though co-morbidity appears to contribute to the risk of frailty beyond the expected additivity of risk due to OA and co-morbidity. Early diagnosis and optimal management of co-morbidities in people with OA may be beneficial.
529 ASSESSING DISCOMFORT AND DISTRESS IN OLDER INPATIENTS WITH DEMENTIA
Authors: West E , Sampson E L , Davies N
Published: June 2021

Introduction

Up to 42% of acute hospital inpatients have dementia. This can make it more difficult for patients to communicate their needs, this in turn may lead to distress and agitation. The aim of this study is to explore the prevalence of distress and discomfort in inpatients with dementia in acute hospitals who may not be able to communicate their needs.

Methods

A series of existing clinical and observational methods were used to measure various aspects of the experience of hospitalised in patients with dementia, and staff working with these patients on wards. These measures looked to identify sources of discomfort, observe the effect of the environment, understand how staff currently identify discomfort and explore associations with behaviours that challenge.

Results

94 patients and their next of kin have been approached; 79 consented to being included in the study, and 67 have been fully assessed. Almost 20% of patients assessed have severe psychiatric problems. ~70% of patients were severely disoriented at assessment. Patients assessed were often sleepy (62%), hadn’t moved for a long period of time (48%) and reported agitation (60%), anxiety (60%) and depression (70%). Staff reported agitation and aggression in 56% of patients, with high frequencies of incidents per patient.

Conclusions

Signs of distress and agitation are common in hospitalised persons with dementia. Patients are often disoriented, which impedes communication of needs. This also has a high burden on staff, as many behavioural and psychiatric symptoms of dementia are experienced daily on wards.
433 SAME SPECIALITY, DIFFERENT REALITY?
Authors: Gomez A , Capon-Saez A , Gomez-Mosquera A , Parada-DeFreitas Y , Arechaderra-Calderon J J , Hoyos E , Jackson H , Ramon-Espinoza F , Vilches-Moraga A
Published: June 2021

Introduction

The United Kingdom and Spain run government-funded social and health care services, free for the user at the point of delivery. Acute Geriatric Units (AGU) carrying out Comprehensive Geriatric Assessments improve the clinical outcomes of older patients. Little is known about the similarities and differences between countries, and how these may impact on clinical outcomes.

Methods

Prospective observational study of consecutive patients admitted to AGU of 2 hospitals in the UK and 4 hospitals in Spain between the 1st to the 30th of October 2019 and from the 1st to the 29th of February 2020. We followed up the patients for a 90 day period.

Conclusions

Frailty, multimorbidity and polypharmacy were prevalent in both cohorts. English patients were younger, with shorter hospital stay, mortality and use of antipsychotic medication but higher readmission rates. Involvement from Allied health care professionals was higher in UK hospitals.
455 PROSPECTIVE EVALUATION OF FRAILTY IN INDIVIDUALS WITH KNEE PAIN IN MALAYSIAN ELDERS LONGITUDINAL RESEARCH (MELOR) STUDY
Authors: Chiew C L , Mat S , Hui K S , Tan M P
Published: June 2021

Introduction

Osteoarthritis (OA) is a major cause of physical impairment in older persons. Few studies have determined the relationship between the presence of OA and frailty. We evaluated the prospective relationship between knee pain and frailty in a Malaysian longitudinal cohort.

Method

Data from Malaysian Elders Longitudinal Research (MELoR) study were utilised. Baseline data were obtained from home-based computer-assisted questionnaires and hospital-based health-checks from 2013–2015. The presence of knee pain was determined with the single question, ‘do you have pain in your knee(s)?’. Frailty status was determined at follow-up in 2019 using SARC-F.

Results

Data from 1,226 individuals, mean age (SD) = 68.97 (7.48), range = 54–97 years and 56.6% women at baseline, were included. 408 (33.3%) had knee pain. Individuals with knee pain were significantly more likely to be female (66.2% vs 51.8%, p < 0.001). Ethnic differences existed in the presence of knee pain (Malay 43.4% vs Chinese 24.8% vs Indian 31.9%, p < 0.001). Individuals with knee pain was more likely to have diabetes (40.1% vs 29.9%, p < 0.001), hypertension (38.3% vs 27.0%, p < 0.001), dyslipidaemia (38.4% vs 26.5%, p < 0.001) and obesity (52.6% vs 30.2%, p < 0.001). After adjustment for confounders, individuals with knee pain were more significantly to develop frailty at follow-up [odds ratio (95% confidence interval) =2.71(1.61–4.58)].

Conclusion

Knee pain was associated with an increased risk of frailty with 5-years follow-up in an urban population in Kuala Lumpur. More detailed evaluation using imaging and clinical diagnosis of osteoarthritis is now indicated. Future studies should also seek to identify modifiable risk factors for the development of frailty in individuals with knee OA and develop strategies to prevent frailty.