Age and Ageing

Taylor-Rowan, M

doi: 10.1093/ageing/afy135.08pmid: N/A

Introduction: Post-stroke cognitive impairment is common but mechanisms and risk factors are poorly understood. Frailty is a condition that may be highly prevalent within the stroke population and could conceivably affect post-stroke cognitive status. We investigated the association between pre-stroke frailty and post-stroke cognition. Method: The Glasgow Royal Infirmary hospital database was utilised. Consecutively admitted acute stroke patients between February 2016 and December 2017 underwent cognitive assessment via the Mini-Montreal Cognitive Assessment, and clinical and demographic information was collected. The Rockwood Frailty Index was employed to generate a frailty score for each patient. Univariate and Multiple linear regression analyses were conducted to investigate the association between pre-stroke frailty and post-stroke cognition. Age, sex, pre-stroke cognitive disorder, delirium & stroke type were included as covariates. Pre-stroke cognition was assessed via medical records (prior history of mild cognitive impairment or dementia), the General Practitioner Assessment of Cognition informant interview, or via a clinical interview using the Clinical Dementia Rating scale; delirium was assessed via the 4 A Test; stroke type was defined according to Bamford classification and was established based upon the clinical impression of the treating stroke consultant. Results: Of 580 patients assessed, sufficient data was available for analysis of 155 patients. Mean age of patients was 68; 60% were male. Frailty prevalence based on Rockwood Frailty index scores of 0.24+ was 38.7%. Pre-stroke cognitive disorder was apparent in 8.4% of patients, and 8.4% of patients screened positive for delirium. Presenting stroke types were 5.3% TACS, 34.8% PACS, 32.2% LACS, 23.2% POCS and 4.5% Unknown. Pre-stroke frailty was significantly associated with post- stroke cognition (p < 0.001) and this effect was independent of covariates (p = 0.023). As pre-stroke frailty scores increased, post-stroke cognition scores declined (B = −0.172). The full model explained a significant amount of variance (p < 0.001; R2 = 0.393). Additional significant variables in the multiple regression model were age (p = 0.001), delirium (p < 0.001), pre-stroke cognitive disorder (p = 0.002). Stroke-type (p = 0.062) and sex (p = 0.546) were not significant. Conclusion: Pre-stroke frailty may be a highly prevalent and important moderator of post-stroke cognition, independent of other well established post-stroke cognitive impairment risk factors. On this basis, recognition of frailty in the stroke population may be important regarding patients’ post-stroke cognitive outcomes. © The Author(s) 2018. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: [email protected] This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) © The Author(s) 2018. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: [email protected]

Borley, K A; Blundell, A G; Gordon, A L

doi: 10.1093/ageing/afy123.02pmid: N/A

Introduction: In many countries, older people in care homes are looked after by dedicated specialist doctors with specific postgraduate training. In the UK, care is provided predominantly by general practitioners with ad hoc input from other specialists. However no competencies are published to ensure doctors are appropriately skilled. We reviewed the international literature for postgraduate competencies that might be applicable to UK care home practice. Methods: EMBASE, MEDLINE, CAB Abstracts and the Joanna Briggs Institute EBP database were searched using a string combining keywords for core competencies AND post-graduate training AND long-term care facilities, limited to English language papers published after 1997. Abstracts were screened and included if describing postgraduate competencies for doctors working in settings equivalent to UK care homes. Included papers were read in full and competencies extracted verbatim. Competencies were then reworded and combined to remove duplication and reflect the terminology and language of UK care homes. Results: 393 papers were identified. 357 and 17 failed eligibility at abstract and full paper stages respectively. The remaining 19 papers yielded 432 competencies, reduced to 62 following removal of duplicates and rewording. The median (IQR) age of included publications was 4 (4.5-11) years and publications came from the USA (15), Canada (2) and Hong Kong (2). Outcomes were mapped to the General Medical Council Generic Professional Capabilities Framework and covered the domains: professional values and behaviour; administrative skills; communication; dealing with complexity; clinical skills; safe prescribing; healthcare systems; leadership; patient safety; quality improvement; safeguarding; education; and research. Conclusion: This scoping review has provided a systematically-derived list of core competencies for postgraduate doctors working in UK care homes. We now propose to use these as the basis of a Delphi exercise to produce a definitive curriculum for UK care home medicine. © The Author(s) 2018. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: [email protected] This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) © The Author(s) 2018. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: [email protected]

Imam, T; Ingram, O; Wilson, T; Mullarkey, D

doi: 10.1093/ageing/afy126.41pmid: N/A

Topic: With an increasing older population with complex comorbidities the current models of care are being stretched and there is a need for integrated services. Current geriatric specialist training is mostly hospital based and most GP training programmes have limited exposure to geriatric medicine placements. To address both a clinical and training need, joint GP and geriatric trainee clinics were created to allowing sharing of expertise and learning whilst improving the delivery of care to older patients. Intervention: We developed a pilot joint clinic model in a GP practice in South West London. 2 Geriatric Specialist Trainees and 2 GP Registrars ran 6 specialist geriatric clinics. 25 patients with complex geriatric needs were identified by GP colleagues and referred into the clinics. The average age was 78 and common themes included cognitive impairment, urinary incontinence, poly-pharmacy and movement disorders. Appointments were extended to 30 minutes to enable comprehensive geriatric assessment. Patient management plans were fed back to referring clinicians in the practice to enable whole practice learning. Improvement: The project was evaluated by qualitative structured interviews with Geriatric Trainees, GP Registrars and Consultant and GP supervisors and patient satisfaction questionnaires. The feedback demonstrated learning for both GP Registrars and Geriatric Trainees in clinical knowledge, service structure and collaborative approaches to patient care. The clinics were enjoyable and added significant value to training for both. The GP Registrars reported developing clinical knowledge and skills relating to the assessment of older patients. The Geriatric Trainees reported the development of communications skills and patient focused approaches relating to primary care. The majority of patients were managed within primary care with 4 referrals generated to secondary care. 6 patient questionnaires were collected with average satisfaction score out of 10 was 9.3. Discussion: This pilot project provides an exciting template to improve both training of GPs and geriatricians, improve the care of the older population and facilitate closer working between primary and secondary care. Barriers to implementation may include the existing service pressures on services to take registrars out of secondary care and to use thirty-minute appointments. Evaluation of cost effectiveness and patient outcomes should be investigated in future studies. © The Author(s) 2018. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: [email protected] This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) © The Author(s) 2018. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: [email protected]

O’Caoimh, R; Condon, M; Liew, A; Lopez-Samaniego, L L; Bakaikoa, O A; Hammar, T; Vanhecke, E; Carriazo, A M; Van der Heyden, J; Carcaillon-Bentata, L; Ranhoff, A H; Rodriguez Laso, A; Galluzzo, L; Hendry, A

Ho, S F; Thomson, A; Kerr, A

doi: 10.1093/ageing/afy127.01pmid: N/A

Introduction: The ability to stand up from a sitting position declines in old age (Manini, 2013). Since manual rehabilitation services are being challenged by the ageing population and budget constraints, patients have sub-optimal access to professional therapists. Technology may offer solutions. A virtual reality based system, aimed at training the sit-to-stand (STS) movements in geriatric population, with visual (3D avatar) and audio feedback on performance (i.e. weight-symmetry loading, muscle strength and upper trunk posture) was developed. The aim of this study was to test the feasibility and clinical effectiveness of this system in a geriatric population undergoing rehabilitation. Methods: A phase two pilot randomised controlled trial (RCT) was conducted at a geriatric rehabilitation unit. All participants underwent two functional assessments (Tinetti Assessment Tools (TAT) and Elderly Mobility Score (EMS)) 48 hours before the study began and at the end of the trial. The experimental group received augmented STS training for four weeks, three sessions a week, while the control group received standard physiotherapy. Results: Sixteen participants (n = 16) completed the trial, eight in each group. No adverse event was recorded during the study period, while the retention rate was 100%. The increase in TAT score (t-value = 2.48) and EMS (t-value = 4.32) in the experimental group were statistically significant (p < 0.05) better than the control. Regarding the system acceptability, participants found it motivating, intuitive and enjoyable. Conclusion: To our knowledge, this is the first RCT evaluating a virtual-reality system that provides automated visual and audio feedback during STS training. The system is feasible and safe in a clinical environment. The computerised biofeedback was found to be superior to standard physiotherapy in recovering the STS movements. Virtual reality systems have the potential to benefit future geriatric rehabilitation. Reference: Manini T. M. (2013). Mobility Decline in Old Age: A Time to Intervene. Exerc Sport Sci Rev, 41(1), 6331. http://doi.org/10.1097/JES.0b013e318279fdc5.Mobility © The Author(s) 2018. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: [email protected] This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) © The Author(s) 2018. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: [email protected]

Marks, J; Sprigg, N; Walker, M

doi: 10.1093/ageing/afy135.09pmid: N/A

Introduction: Stroke causes more complex disability in adults than any other disorder. Excess TNFα (tumour necrosis factor-alpha) has been widely implicated in the pathophysiology of post-stroke neuroinflammation; a cause of overt neurodegeneration. Etanercept, a biologic TNFα inhibitor, may attenuate elevated TNFα in the post-stroke brain, to limit neuronal injury and improve functional outcomes for patients. The objective of this review was to determine whether Etanercept reduces infarct volume and/or improves functional outcome after stroke. Methods: The Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE, EMBASE and PubMed (last searched November 2017) were searched for experimental and clinical studies whereby Etanercept was administered after stroke of any type. A secondary search of relevant reference lists was conducted and trial registers were also searched (November 2017). All routes of administration, doses and periods from stroke onset to treatment were accepted. The primary outcome in experimental studies was infarct volume; secondary outcomes included cerebral apoptosis and neurological deficit. In clinical studies, functional outcome (measured by the Modified Rankin Scale) was the primary outcome measure. Secondary outcomes included adverse events, pain, spasticity and motor and cognitive deficit. Results: The original search retrieved 5297 results; after removal of duplicates and screening against eligibility criteria, 10 experimental and 2 clinical studies were included for review. Mean experimental study quality was 4.2 of 8 and significant inter-study heterogeneity existed. Infarct volume was reduced in all studies whereby intraperitoneal administration before reperfusion occurred. Intravenous administration, or administration after reperfusion was non-therapeutic. Improved neurological deficit was associated with higher Etanercept doses. No firm association between effect on infarct and resulting neurological outcome could be drawn. Clinical studies were observational and open-label. No studies collected data on the primary outcome. Perispinal administration of Etanercept to patients with chronic post-stroke disability demonstrated improvement across multiple domains but meaningful conclusions were not possible due to the lack of a comparator arm. Mean reduction in time to walk 20 m, as measured immediately after treatment, was 7.8 seconds and 73.1% patients had reduced pain 3 weeks post-treatment. Deaths and adverse events were subject to selective reporting. Conclusions: More robust data, by way of high quality experimental studies, is needed to resolve contradictions regarding the efficacy of Etanercept before randomised controlled trials can be conducted in humans. © The Author(s) 2018. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: [email protected] This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) © The Author(s) 2018. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: [email protected]

Taylor-Rowan, M; Quinn, T; Smith, P; Ellis, G; Keir, R; McAlpine, C; Marsh, G; Murtagh, J; McElroy, M; Mitchell, L; Waddell, G; Williams, A; Duffy, L; Oswald, S; Myles, A; Bann, A; Rodger, K; Reid, J;

Walsh, E; Ragavan, S

doi: 10.1093/ageing/afy124.08pmid: N/A

Introduction: Patients presenting with fragility fractures are usually screened for potential causes of poor bone health. Evidence shows those with HIV are at risk of early development of age related conditions, including osteoporosis. With rising prevalence of HIV in older age groups, should HIV screening form part of routine assessment of patients with fragility fractures? Methods: We assessed patients aged 50–75 yrs admitted to hospital with a fractured neck of femur over three months. They were given a questionnaire based on trust guidelines to establish existing risk factors for osteoporosis. Consent was obtained for HIV testing; this was included with routine bone health screening. Patients were excluded if they were unable to consent to HIV testing. Results: During the study we screened a total of 21 patients. Of these, one was HIV positive (4.8%), although this was a previously diagnosed case. This is higher than the national average of 0.16%, however these results are not statistically significant due to the small sample size. It is also notable that the most common risk factors for osteoporosis were smoking (16/21) and alcohol excess (8/21), indicating the importance of lifestyle factors in bone health. Conclusion: This study demonstrates the possibility for above average prevalence of HIV in patients with fragility fractures. However due to the sample size results were not statistically significant, and HIV diagnosis was not new, meaning fragility fracture as a first presentation of HIV has yet to be shown. It would be useful to expand the study to include further types of fragility fractures over a longer period to increase sample size. Identifying those who are HIV positive reduces onward transmission, and avoids the significant costs associated with late diagnosis, allowing HIV testing to be cost effective even at low identification rates. © The Author(s) 2018. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: [email protected] This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) © The Author(s) 2018. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: [email protected]

Chow, P C L; Lim, S C

doi: 10.1093/ageing/afy118.05pmid: N/A

Introduction: Delirium is common in elderly in the early post-operative period. They are usually admitted in the surgical unit. Undiagnosed delirium would impair the surgical recovery and subsequent rehabilitation. A prompt diagnosis of delirium and a precise analysis of its causes are paramount in this crucial period for satisfactory outcomes. We determined the common culprits in post-operative delirium in the elderly in a series of 25 cases. Methods: We started Surgical-Geriatric Service on July 2015. Twenty-five inpatient referrals, from July 2015 to Dec 2015, from Department of Surgery to Department of Geriatric Medicine were reviewed by two geriatricians and data were collected for analysis. Results: In the 25 cases, 68% were male patients. The mean age was 82 years old. Thirty-six percent of the operations were elective. Sixty percent had background of dementia. Eighty percent required assistance in Instrumental Activity of Daily Living (IADL), however, the mean Barthel Index for Basic Activity of Daily Living (BADL) was 18.5, out of 20. Most patients (64%) developed delirium in first 3 days after operation. During the assessment by geriatricians, 80% of patients were in inadequate pain control, 48% were in medications with high risk of delirium (metoclopramide, tramadol, pethidine, hydroxyzine, piriton), 64% were having active sepsis and 100% had constipation. More than half of the patients (60%) had mixed delirium, 24% had hyperactive delirium and 16% had hypoactive delirium. Consequently, 64% had physical restraint during the assessment and 12% had chemical restraint. Conclusion: Inadequate pain control, use of high risk medications, active sepsis and constipation were the most common culprits in post-operative delirium in the elderly early after general surgical operation. Assessment by geriatricians will be helpful in early detection of delirium with its causes and, hence, the managements to improve the outcomes and recovery of the elderly after operation. © The Author(s) 2018. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: [email protected] This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) © The Author(s) 2018. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: [email protected]

Cox, M; Gaffing, S; Rose, L; Ramanath, R

doi: 10.1093/ageing/afy126.30pmid: N/A

Topic: Constipation affects up to 45% of adults aged over 65 in the UK. We observed complications assosciated with under-diagnosing constipation including pain, delirium, urinary tract infections and prolonged admissions. The aim of this project was to improve the consistency and frequency of documentation of bowel movements, to better recognise constipation. Work was undertaken on the care of the elderly unit at Doncaster Royal Infirmary. Demographics and data related to bowel movements from nursing notes and bedside stool charts were gathered weekly on all inpatients for 3 weeks during each round of data collection. Intervention: Round 1: Structured education offered to nursing staff and healthcare assistants. Prompting to document bowel movements encouraged through posters and notes on nursing trollies. Round 2: Trust stool chart redesigned to include a tick box to indicate bowels not opened. The aim was to prompt for healthcare staff to document bowel movements daily even if bowels had not been opened, as well as making the charts as quick to complete as possible. Improvement: Data were obtained on 423 patients with a mean age of 85 years, 65.9% were female, 43% of which had a diagnosis of dementia. . Baseline . Round 1 . Round 2 . Significance (Round 2 compared to baseline) . Percentage of patients with stool chart 88% 87% 94% 0.001 Average days since stool chart completed 2.13 1.65 1.10 0.001 Average days since bowels open on stool chart 2.19 3.03 2.07 - Average days since nursing notes completed 0.82 1.01 0.75 0.04 Percentage of stool charts and nursing notes matching 19% 33% 49% 0.001 . Baseline . Round 1 . Round 2 . Significance (Round 2 compared to baseline) . Percentage of patients with stool chart 88% 87% 94% 0.001 Average days since stool chart completed 2.13 1.65 1.10 0.001 Average days since bowels open on stool chart 2.19 3.03 2.07 - Average days since nursing notes completed 0.82 1.01 0.75 0.04 Percentage of stool charts and nursing notes matching 19% 33% 49% 0.001 Open in new tab . Baseline . Round 1 . Round 2 . Significance (Round 2 compared to baseline) . Percentage of patients with stool chart 88% 87% 94% 0.001 Average days since stool chart completed 2.13 1.65 1.10 0.001 Average days since bowels open on stool chart 2.19 3.03 2.07 - Average days since nursing notes completed 0.82 1.01 0.75 0.04 Percentage of stool charts and nursing notes matching 19% 33% 49% 0.001 . Baseline . Round 1 . Round 2 . Significance (Round 2 compared to baseline) . Percentage of patients with stool chart 88% 87% 94% 0.001 Average days since stool chart completed 2.13 1.65 1.10 0.001 Average days since bowels open on stool chart 2.19 3.03 2.07 - Average days since nursing notes completed 0.82 1.01 0.75 0.04 Percentage of stool charts and nursing notes matching 19% 33% 49% 0.001 Open in new tab Discussion: Our work demonstrates a significant improvement in the frequency and consistency of the documentation of bowel movements over an 8 month period through increased staff awareness and improved ease of documentation. However, further work is needed to improve consistency between nursing documentation and stool charts. The challenge also remains of maintaining improved standards once weekly monitoring ceases. © The Author(s) 2018. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: [email protected] This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) © The Author(s) 2018. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: [email protected]