Age and Ageing

Sawney, P; Rehman, H; Ali, S; Alicehajic-Becic, D; Clarke, E; Khan, K; Roughneen, K; Leigh, E

doi: 10.1093/ageing/afac322.103pmid: N/A

IntroductionNICE guidance recommends that doctors need to identify patients who are approaching their final year of life, through the utilisation of tools such as the Clinical Frailty Score (CFS). The ‘Getting it right first time’ (GIRFT) document recommended that all local health systems identify older people in the last phase of life and offer them Advanced Care Planning (ACP). Wigan has a large population of frail patients who would benefit from ACP discussions.AimInitiate a strategy for identifying patients with severe frailty and establish a process for implementing ACP.MethodRetrospective discharge data was used to identify patients aged >65 years, with a CFS of >7, over an 8-week period. The cohort was examined to see if they had been recognised as a patient who would benefit from ACP, or if an aspect of ACP had been completed during their admission. In total, 19 patients were identified, of which 6 were included and 13 were excluded.ResultsInitial data showed that we were poor at identifying and completing ACPs for patients with severe frailty. No advanced care planning decisions (0%) were taken during this period. Education (PDSA cycle 1) on ACPs for the ward doctors led to an improvement regarding ACP discussions. However, we were still poor at identifying severe frailty. Education (PSDA cycle 2) for nursing staff was undertaken, which highlighted inaccuracies with calculating CFS. Further PDSA cycles are to follow, including a geriatric frailty score assessment, introduction of Electronic Palliative Care Coordination Systems (EPACCS) and frailty posters and cards.ConclusionSevere frailty is an end-of-life state and should trigger a healthcare professional to identify and sensitively discuss end of life needs and preferences. ACP should be disseminated to other healthcare professionals to allow them to act in accordance with the patient’s wishes or best interests.

Ma, N; Low, S; Hasan, S; Banna, S; Patel, S; Kalsi, T

doi: 10.1093/ageing/afac322.090pmid: N/A

IntroductionThe prevalence of eye disease and visual impairment in care home residents is disproportionately higher compared to the general population. Access to eye care services and treatment can be variable for this vulnerable population.ObjectiveThis narrative synthesis reviews the available evidence of services and interventions for delivering eye care to care home residents. The key review questions:What is the existing evidence for eye care interventions or services (including service configuration) for care home residents?Does the provision of these interventions or services improve outcomes?MethodsLiterature search of EMBASE/MEDLINE for original papers published since 1995. Two reviewers independently reviewed abstracts/papers. Data was extracted and evaluated using narrative synthesis.Results13 original papers met the inclusion criteria. On-site optometrist-led services improved diagnosis and management of eye conditions, with one study showing 53% of residents benefited from direct ophthalmology intervention. Provision of interventions such as cataract surgery, refractive error correction and low vision rehabilitation improved visual acuity and vision-related quality of life but did not improve cognitive or physical function, depression or health-related quality of life. There was little UK-based literature to inform eye service design or interventions to improve outcomes.ConclusionCare home-based eye assessments improve the management of eye conditions. Interventions improve visual acuity and vision-related quality of life. Further research and/or clinical service scoping is needed to better understand current UK services, access difficulties or examples of good practice as well as to identify and test cost-effective service models for this vulnerable group.

Manietta, C; Purwins, D; Reinhard, A; Pinkert, C; Fink, L; Feige, M; Knecht, C; Roes, M

doi: 10.1093/ageing/afac322.032pmid: N/A

IntroductionDementia-friendly hospitals (DFH) are mentioned as one of several key initiatives in national dementia strategies. In our previous integrative review, we identified 17 descriptions of DFHs and analysed six characteristics of DFH: continuity, person-centredness, consideration of phenomena within dementia, environment, valuing relatives and knowledge and expertise within the hospital (Manietta, Purwins, Reinhard et al., BMC Geriatrics, 2022, 22, 468, 1-16). We also learned that the term DFH is based more on healthcare practice than research. To address this research gap, one step of our DEMfriendlyHospital study is to examine the perspectives of professional dementia experts working in hospitals in Germany.MethodWe used a qualitative design and conducted 14 semi-structured interviews with professional dementia experts from various healthcare professions (12 nurses, two physicians, and one physiotherapist). Data were collected between November 2021 and March 2022. Using an inductive content analysis, we furthermore analysed the interviews in a participatory way involving a group of research associates and professional dementia experts.ResultsFrom the professional dementia experts’ perspectives, a DFH is characterised by specific hospital processes, structures and environment which consider the needs of people with dementia, dementia-specific knowledge and the skills of hospital staff, their awareness and attitude towards people with dementia. A DFH needs the social inclusion of patients with dementia and their perception as a person as well as the involvement of relatives, who are an important support for the patients and their care.ConclusionThere are links between our results from interviews with professional dementia experts and our integrative review. At the same time, the perspectives of patients with dementia and their relatives are underrepresented. To fill this gap, our next step is to interview people with dementia who are hospitalised and their relatives, aiming to enhance the description of a DFH and its characteristics.

Rommerskirch-Manietta, M; Purwins, D; Van Haitsma, K; Abbott, K; Roes, M

doi: 10.1093/ageing/afac322.033pmid: N/A

IntroductionCommunity-based care such as adult day services (ADS) are preferred by people with dementia. ADS offers the opportunity to support the health and social needs of their clients and provide respite to family members, contributing to a stable care situation at home. The psychological needs of humans according to the self-determination-theory (SDT) (autonomy, competence, and relatedness) can be fulfilled by leisure activities and thus improve well-being and quality of life. The implementation of leisure activities that reflect individual preferences support active participation, preserve autonomy, improve satisfaction with care and consequently can be understood as a core aspect of person-centred care. However, it is currently unknown how people receiving ADS understand leisure and which leisure activities they prefer.MethodTo gain insight, a qualitative design was chosen. We conducted semi-structure interviews with 13 people receiving ADS in Germany. Participants were recruited from two different ADS in one state in Germany. Interviews were recorded, transcribed verbatim and analysed using thematic analysis and categories of the SDT.ResultsThe results show that over 90 % of participants were diagnosed with dementia and that the ADS was considered a place to participate in leisure activities. However, this consideration depends primarily on the degree of autonomy they experienced and thus the freedom to choose activities in the ADS according to their individual preferences. The participants mentioned a variety of preferred meaningful leisure activities related to competence and relatedness (e.g., mentoring, socializing, reminiscence).ConclusionThe results indicate the importance of preference-based service design in ADS to meet clients’ psychological needs and thus provide person-centred care to improve well-being and quality of life. These results can be used to develop an item-based assessment tool to assess the preferences of people with care needs regarding leisure activities in ADS.

Ellis, S; Bacon, I; Long, S; Buxton, K; Klinkhamer, F

doi: 10.1093/ageing/afac322.063pmid: N/A

IntroductionThe National End of Life Care Strategy highlighted the need for individualised care plans accessible to the multi-disciplinary team. Care planning tools have been shown to improve documentation, with proformas providing a systematic approach to recording EOL discussions. Our initial staff survey highlighted a lack of familiarity with required EOLC documentation. We aimed to increase awareness of existing documentation proformas and to improve EOLC documentation on an elderly care ward.MethodsA Driver Diagram increased understanding of the principles underlying excellent EOLC and aided development of change ideas. The Model for Improvement allowed identification of measurable aims. 20 patient notes were reviewed fortnightly, including patients who had died since the previous intervention.ResultsThree PDSA cycles were completed, changes were measured by evaluating patient documentation. The first PDSA cycle involved providing training to nursing colleagues. Step-by-step teaching on the use of Cerner EOL documentation demonstrated a 15% increase in completed care plans. The second cycle (placing posters around the ward) - detailing how to access and document care plans resulted in a 5% increase. The third cycle (25% improvement) involved education sessions for ward doctors.ConclusionsComprehensive documentation is key to ensuring good EOLC, as it enables continuity of care and improves MDT communication. Withdrawal of the Liverpool Care Pathway resulted in a need for individualised care plans. Active interventions including face-to-face teaching were more effective than passive (posters) in improving documentation. Limitations included small sample sizing, likely due to a lack of engagement with questionnaires and inclusion criteria. Only documentation of deceased patients was analysed, excluding patients discharged home or transferred to hospice. We aim to extend to other elderly care wards and to integrate documentation training into junior doctor induction. A review of existing EOL proformas and their ease of access may also be considered.

Monnier-Hovell, Z; Jundi, A; Sims, H; Sheikh, A

doi: 10.1093/ageing/afac322.012pmid: N/A

IntroductionThe British Geriatrics Society (BGS) Flexible Workforce Statement supports national policy such as the NHS People Plan in promoting less than full time (LTFT) working.1,2 As LTFT trainee representatives on the BGS Trainees' Council we were interested to know how consultant work patterns are advertised. We analysed job adverts for Consultants in Geriatric Medicine over a two-year period to identify how many were LTFT posts.MethodA freedom of information (FOI) request was submitted to online recruitment website ‘NHS Jobs’. The request identified jobs in ‘Elderly Care Medicine’ OR those containing ‘Geriatric’ in their title between 01/04/2019 and 31/03/2021. The FOI data were filtered to only include Consultant posts, grouped by training deanery and analysed using Excel. Regional numbers of LTFT trainees were identified by emailing Training Programme Directors and a FOI request to deaneries for non-responders. The number of LTFT consultants was identified using the online Royal College of Physicians census.3ResultsThe FOI request returned 7589 jobs; of these 1083 were consultant posts. These ranged from 42 in Thames Valley to 171 in East of England. Twenty-one jobs (1.9%) were advertised as LTFT, the highest proportion was 10.5% in Yorkshire and Humber. Twenty-eight (2.6%) were negotiable, the highest proportion was 15.9% in the South West. On average, 33% of LTFT jobs were advertised as permanent posts. Currently, 37.7% of trainees, and 25% of consultants, work LTFT.ConclusionNumber of LTFT job adverts was low compared to the number of LTFT consultants and trainees, although there is regional variation. A limitation was that details of adverts were not seen, which made it unclear whether each job was a fresh advert or readvertising an unfilled post. The latter is likely given there are 1747 consultants working in the UK.3 Further avenues of work include identifying LTFT opportunities for SAS grade doctors and allied health professionals.References1. https://www.england.nhs.uk/ournhspeople/online-version/lfaop/2. https://www.bgs.org.uk/resources/flexible-working-in-geriatric-medicine3. https://www.rcplondon.ac.uk/projects/outputs/working-differently-shadow-covid-19-uk-2021-census-consultant-higher-specialty

Moore, A; Glogowska, M; Lasserson, D; Hayward, G

doi: 10.1093/ageing/afac322.051pmid: N/A

IntroductionOlder people living in care homes sometimes experience episodes of acute functional decline. These represent a diagnostic challenge to healthcare professionals and can result in antibiotic prescriptions or hospital admissions, though this may not always the most appropriate management strategy. We aimed to understand how episodes of acute functional decline are recognised, managed and escalated by care home staff in the UK.MethodThis was a qualitative interview study with UK care home staff, including managers, nurses and carers. Participants were recruited through advertisements circulated via email, social media and word of mouth. Semi-structured interviews were conducted over the phone between January 2021 and April 2022. Thematic analysis was facilitated by NVivo software.Results25 care home staff were interviewed. Participants described feeling confident in recognising when residents were less well than usual, especially if they knew them well. However, they sometimes felt it was difficult to differentiate between an ‘off day’ and something more significant. Most participants talked about clear early communication amongst the team to flag a resident of concern. Initial management steps in the care home included checking clinical observations and doing a urine dipstick. Many participants talked about considering the underlying cause for deterioration. Some participants felt comfortable monitoring residents for a few days themselves or trying a simple intervention. Others preferred escalating directly to outside clinical support. Triggers for escalation included perceived severity of illness, gut feeling or failure to respond to initial supportive management.ConclusionsThese results highlight the skill base of care home staff. However, it has also helped to identify areas for additional support and training including the use and interpretation of the urine dipstick. The findings of this study are being used to inform the design of a feasibility prospective cohort study of UK care home residents.

Ralston, K; Degnan, A; Groom, C; Leonard, C; Munang, L; Japp, A; Rimer, J

doi: 10.1093/ageing/afac322.070pmid: N/A

IntroductionHeart failure (HF) is a common problem managed in our West Lothian multi-disciplinary hospital at home (HaH) service, however significant variation in practice was noted with considerable resource implications. We aimed to standardise and improve this by developing a dedicated protocol.MethodsWe developed a protocol to guide the assessment and management of HF within HaH. We collected baseline (n=25) and follow-up data (n=10) after protocol introduction from patients referred to HaH with heart failure. Outcomes reviewed included anticipatory care planning (ACP) decisions, length of stay (LOS) and treatment strategy. We held staff education sessions and surveyed staff confidence regarding HF management.ResultsACP discussion rates improved after protocol introduction, with decision rates improving for both escalation of care (28% to 80%) and resuscitation (44% to 60%). LOS reduced after protocol introduction (mean 6.3 days to 5.9 days). Titration of oral diuretics alone (71%) was associated with a shorter LOS (mean 5.4 days) compared to IV (29%, mean 8.1 days), with no difference in 28 day outcome. In those with HF with reduced ejection fraction, the rates of beta-blocker prescription increased (57% to 80%) however ACE-inhibitor prescription decreased (29% to 20%). Use of add-on therapy (e.g. thiazide diuretics) increased (12% to 30%) with a decrease in complication rates (12% to 0%). All staff found the protocol helpful with an improvement in confidence levels.ConclusionsThrough introducing a standardised protocol, we observed an improvement in anticipatory care discussion rates and a trend towards shorter LOS. Oral diuretic titration was less resource intensive without an adverse impact on outcome. Future plans include ongoing education and data collection, trialling a joint multi-disciplinary meeting with cardiology for discussion of complex patients and embedding a treatment strategy of oral diuretic titration with a ‘discharge with planned review' approach in appropriate patients.

Murtagh, F E M; Okoeki, M; Ukoha-kalu, B O; Khamis, A; Clark, J; Boland, J W; Pask, S; Nwulu, U; Elliott-Button, H; Folwell, A; Johnson, M J; Harman, D

doi: 10.1093/ageing/afac322.026pmid:

Parkinson, M; Doherty, R; Curtis, F; Dani, M; Fertleman, M; Kolanko, M; Soreq, E; Barnaghi, P; Sharp, D; Li, L M; ,

doi: 10.1093/ageing/afac322.040pmid: N/A

IntroductionMajor trauma including Traumatic Brain Injury (TBI) is an increasingly common cause of hospitalisation in older adults (OAs). We studied post-discharge recovery from TBI using a remote healthcare monitoring system that captures data on activity and sleep. We aim to assess the feasibility and acceptability of this technology to monitor recovery at home following a significant acute health event in OAs.MethodsWe installed Minder, a remote healthcare monitoring system, in recently discharged patients >60 years with moderate-severe TBI. We present descriptive analyses of post-discharge recovery for two males, corroborating data from Minder against verified activities and events. We recorded semi-structured interviews assessing acceptability. Both participants have similar household set-up, multimorbidity profiles and clinical frailty scores; however, one participant has prior cognitive impairment (PAT1), and one does not (PAT2).ResultsWe present 10 weeks of sleep and activity data from Minder and feedback from interviews. Data observed from PAT1 revealed habitual patterns of activity and sleep. These remained stable, despite discrete clinical events. Conversely, PAT2's data revealed irregular sleep patterns that became increasingly fragmented. Activity was detected in multiple rooms throughout the house at night, consistent with carer reports of night-time wandering. Increased overnight activity coincided with multiple falls, prompting increased care provision. Initial feedback from interviews was the technology helped participants and those involved in their care feel supported.ConclusionsAs pressure on services mounts, novel approaches to post-discharge care are of increasing importance. Remote healthcare monitoring can provide high temporal resolution data offering ‘real world’ insights into the effects of significant health events in OAs. Our provisional results support our hypothesis that use of this technology is feasible and acceptable for frail, multimorbid participants and highlights the substantial potential of this technology to help clinicians improve community-based care and more effectively monitor interventions and chronic conditions.