Development and validation of a trauma frailty scale in severely injured patients: the Nottingham Trauma Frailty Index

Aims

Frailty greatly increases the risk of adverse outcome of trauma in older people. Frailty detection tools appear to be unsuitable for use in traumatically injured older patients. We therefore aimed to develop a method for detecting frailty in older people sustaining trauma using routinely collected clinical data.

Methods

We analyzed prospectively collected registry data from 2,108 patients aged ≥ 65 years who were admitted to a single major trauma centre over five years (1 October 2015 to 31 July 2020). We divided the sample equally into two, creating derivation and validation samples. In the derivation sample, we performed univariate analyses followed by multivariate regression, starting with 27 clinical variables in the registry to predict Clinical Frailty Scale (CFS; range 1 to 9) scores. Bland-Altman analyses were performed in the validation cohort to evaluate any biases between the Nottingham Trauma Frailty Index (NTFI) and the CFS.

Results

In the derivation cohort, five of the 27 variables were strongly predictive of the CFS (regression coefficient B = 6.383 (95% confidence interval 5.03 to 7.74), p < 0.001): age, Abbreviated Mental Test score, admission haemoglobin concentration (g/l), pre-admission mobility (needs assistance or not), and mechanism of injury (falls from standing height). In the validation cohort, there was strong agreement between the NTFI and the CFS (mean difference 0.02) with no apparent systematic bias.

Conclusion

We have developed a clinically applicable tool using easily and routinely measured physiological and functional parameters, which clinicians and researchers can use to guide patient care and to stratify the analysis of quality improvement and research projects.

The Difficulties of Managing Pain in People Living with Frailty: The Potential for Digital Phenotyping

Pain and frailty are closely linked. Chronic pain is a risk factor for frailty, and frailty is a risk factor for pain. People living with frailty also commonly have cognitive impairment, which can make assessment of pain and monitoring of pain management even more difficult. Pain may be sub-optimally treated in people living with frailty, people living with cognitive impairment and those with both these factors. Reasons for sub-optimal treatment in these groups are pharmacological (increased drug side effects, drug-drug interactions, polypharmacy), non-pharmacological (erroneous beliefs about pain, ageism, bidirectional communication challenges), logistical (difficulty in accessing primary care practitioners and unaffordable cost of drugs), and, particularly in cognitive impairment, related to communication difficulties. Thorough assessment and characterisation of pain, related sensations, and their functional, emotional, and behavioural consequences ("phenotyping") may help to enhance the assessment of pain, particularly in people with frailty and cognitive impairment, as this may help to identify who is most likely to respond to certain types of treatment. This paper discusses the potential role of "digital phenotyping" in the assessment and management of pain in people with frailty. Digital phenotyping is concerned with observable characteristics in digital form, such as those obtained from sensing-capable devices, and may provide novel and more informative data than existing clinical approaches regarding how pain manifests and how treatment strategies affect it. The processing of extensive digital and usual data may require powerful algorithms, but processing these data could lead to a better understanding of who is most likely to benefit from specific and targeted treatments.

The association of painful and non-painful morbidities with frailty: a cross sectional analysis of a cohort of community dwelling older people in England

INTRODUCTION

The association between chronic pain and frailty might indicate that pain is an independent driver of frailty but might alternatively be explained by inclusion within frailty identification tools of morbidities that commonly lead to chronic pain. This research examines the extent to which the association of pain with frailty might be attributed to morbidities.

METHODS

A cross-sectional analysis of older people in a UK cohort with or at risk of musculoskeletal problems or frailty (Investigating Musculoskeletal Health and Wellbeing study), used multivariable logistic regression and Z-tests to assess the degrees of associations of pain (McGill Pain Rating Index), and painful and non-painful morbidity counts with frailty (modified FRAIL questionnaire).

RESULTS

Data were from 2,185 participants, 56% female, median age 73 (range 60 to 96) years. 430 (20%) participants were classified as frail. In a fully adjusted standardised model, pain (aOR 2.07 (95%CI 1.83 to 2.33) and 'any' morbidity aOR (1.74 (95%CI 1.54 to 1.97) were both significantly associated with frailty. When morbidity was subclassified as painful or non-painful, painful (aOR 1.48 (95%CI 1.30 to 1.68) and non-painful (aOR1.39 (95%CI 1.24 to 1.56)) morbidities each were associated with frailty, as also was pain (aOR 2.07 (95%CI 1.83 to 2.34, p < 0.001).

CONCLUSIONS

Pain is associated with frailty, over and above any effect of painful and non-painful morbidities. This forms the justification for future research which focuses on pain management in the identification, prevention, and treatment of frailty.

The effects of neuromuscular electrical stimulation on hospitalised adults: systematic review and meta-analysis of randomised controlled trials

INTRODUCTION

Neuromuscular electrical stimulation (NMES) is a treatment to prevent or reverse acquired disability in hospitalised adults. We conducted a systematic review and meta-analysis of its effectiveness.

METHOD

We searched MEDLINE, EMBASE, Cumulative Index to Nursing & Allied Health (CINAHL) and the Cochrane library. Inclusion criteria: randomised controlled trials of hospitalised adult patients comparing NMES to control or usual care. The primary outcome was muscle strength. Secondary outcomes were muscle size, function, hospital length of stay, molecular and cellular biomarkers, and adverse effects. We assessed risk of bias using the Cochrane risk-of-bias tool. We used Review Manager (RevMan) software for data extraction, critical appraisal and synthesis. We assessed certainty using the Grading of Recommendations Assessment, Development and Evaluation tool.

RESULTS

A total of 42 papers were included involving 1,452 participants. Most studies had unclear or high risk of bias. NMES had a small effect on muscle strength (moderate certainty) (standardised mean difference (SMD) = 0.33; P < 0.00001), a moderate effect on muscle size (moderate certainty) (SMD = 0.66; P < 0.005), a small effect on walking performance (moderate certainty) (SMD = 0.48; P < 0.0001) and a small effect on functional mobility (low certainty) (SMD = 0.31; P < 0.05). There was a small and non-significant effect on health-related quality of life (very low certainty) (SMD = 0.35; P > 0.05). In total, 9% of participants reported undesirable experiences. The effects of NMES on length of hospital stay, and molecular and cellular biomarkers were unclear.

CONCLUSIONS

NMES is a promising intervention component that might help to reduce or prevent hospital-acquired disability.

"Crack on": a qualitative study of care home managers experiences and responses to system-led setbacks during the crisis of the COVID-19 Pandemic in England

OBJECTIVES

To explore care home managers' experiences of systems working with various organisations, including statutory, third sector and private, during the second wave of the COVID-19 pandemic from Sept 2020 to April 2021 DESIGN: An exploratory qualitative interview study using a systems theory approach focussing on the intersections of relationship interdependencies with other organisations.

SETTING

Conducted remotely with care home managers and key advisors who had worked since the start of the pandemic in/with care homes for older people across the East Midlands, UK.

PARTICIPANTS

8 care home managers and 2 end-of-life advisors who participated during the second wave of the pandemic from Sept 2020. A total of 18 care home managers participated in the wider study from April 2020 to April 2021 RESULTS: Four organisational relationship interdependencies were identified: care practices, resources governance and wise working. Managers identified changes in their care practices as a shift towards the normalisation of care, with an emphasis on navigating pandemic restrictions to fit the context. Resources such as staffing, clinical reviews, pharmaceutical and equipment supplies were challenged, leading to a sense of precarity and tension. National polices and local guidance were fragmented, complex and disconnected from the reality of managing a care home. As a response a highly pragmatic reflexive style of management was identified which encompassed the use of mastery to navigate and in some cases circumvent official systems and mandates. Managers' experience of persistent and multiple setbacks were viewed as negative and confirmed their views that care homes as a sector ere marginalised by policy makers and statutory bodies.

CONCLUSIONS

Interactions with various organisations shaped the ways in which care home managers responded to and sought to maximise residents and staff well-being. Some relationships dissolved over time, such as when local business and schools returned to normal obligations. Other newly formed relationships became more robust including those with other care home managers, families, and hospices. Significantly, most managers viewed their relationship with local authority and national statutory bodies as detrimental to effective working, leading to a sense of increased mistrust and ambiguity. Respect, recognition and meaningful collaboration with the care home sector should underpin any future attempts to introduce practice change in the sector.

The bidirectional relationship between chronic joint pain and frailty: data from the Investigating Musculoskeletal Health and Wellbeing cohort

BACKGROUND

Pain and frailty are associated, but this relationship is insufficiently understood. We aimed to test whether there is a unidirectional or bidirectional relationship between joint pain and frailty.

METHODS

Data were from Investigating Musculoskeletal Health and Wellbeing, a UK-based cohort. Average joint pain severity over the previous month was assessed using an 11-point numerical rating scale (NRS). Frailty was classified as present/absent using the FRAIL questionnaire. Multivariable regression assessed the association between joint pain and frailty, adjusted for age, sex, and BMI class. Two-wave cross-lagged path modelling permitted simultaneous exploration of plausible causal pathways between pain intensity and frailty at baseline and 1-year. Transitions were assessed using t-tests.

RESULTS

One thousand one hundred seventy-nine participants were studied, 53% female, with a median age of 73 (range 60 to 95) years. FRAIL classified 176 (15%) participants as frail at baseline. Mean (SD) baseline pain score was 5.2 (2.5). Pain NRS ≥ 4 was observed in 172 (99%) of frail participants. Pain severity was associated with frailty at baseline (aOR 1.72 (95%CI 1.56 to 1.92)). In cross-lagged path analysis, higher baseline pain predicted 1-year frailty [β = 0.25, (95%CI 0.14 to 0.36), p < 0.001] and baseline frailty predicted higher 1-year pain [β = 0.06, (95%CI 0.003 to 0.11), p = 0.040]. Participants transitioning to frailty over one year had higher mean pain scores (6.4 (95%CI 5.8 to 7.1)) at baseline than those who remained non-frail (4.7 (95%CI 4.5 to 4.8)), p < 0.001.

CONCLUSIONS

The bidirectional relationship between pain and frailty could lead to a vicious cycle in which each accelerates the other's progression. This justifies attempts to prevent frailty by addressing pain and to include pain measures as an outcome in frailty studies.

Does frailty status predict outcome in major trauma in older people? A systematic review and meta-analysis

INTRODUCTION

The incidence of major trauma in older people is increasing. Frailty is likely to be a factor that influences the outcomes of trauma. We conducted a systematic review aiming to investigate whether frailty affects major trauma outcomes in older people and whether it is more predictive than age.

METHODS

Observational studies investigating frailty, major trauma severity and outcomes were eligible. We searched electronic databases (Ovid MEDLINE, PubMed, Ovid EMBASE and CINAHL) from 2010 to 01 January 2023. We used Joanna Briggs Institute software to assess the risk of bias and conduct meta-analyses of the relationships between frailty status and outcomes. We used a narrative synthesis to compare the predictive value of frailty and age.

RESULTS

Twelve studies were eligible for meta-analyses. In-hospital mortality (odds ratio (OR) = 1.12, 95% confidence interval (CI) 1.05, 1.19), length of stay (OR = 2.04, 95% CI 1.51, 2.56), discharge to home (OR = 0.58, 95% CI 0.53, 0.63) and in-hospital complications (OR = 1.17, 95% CI 1.10, 1.24) were all associated with frailty. Frailty was found to be a more consistent predictor of adverse outcomes and mortality in older trauma patients than injury severity and age in six studies that reported multivariate regression analysis.

DISCUSSION

Older trauma patients with frailty have higher in-hospital mortality rates, prolonged hospital stays, in-hospital complications and adverse discharge disposition. Frailty is a better predictor of adverse outcomes than age in these patients. Frailty status is likely to be a useful prognostic variable in guiding patient management and stratifying clinical benchmarks and research trials.

1321 THE ASSOCIATION OF PAINFUL AND NON-PAINFUL COMORBIDITIES WITH FRAILTY

Introduction

Chronic pain is associated with frailty. We hypothesised that painful comorbidities would be more strongly associated with frailty than non-painful comorbidities.

Method

Data were from Investigating Musculoskeletal Health and Wellbeing, a UK-based cohort of people with or at risk of musculoskeletal problems or frailty. Average pain over the previous month was assessed using an 11-point numerical rating scale (NRS). The original FRAIL questionnaire comprises five self-report items: Fatigue, Resistance, Ambulation, Illnesses and Loss of weight. In this study risk of frailty was operationalised using a modified FRAIL questionnaire, omitting the “illnesses” item which related to comorbidities. Comorbidities were classified as either ‘painful’ or ‘non-painful’ based on the International Association for the Study of Pain chronic pain classification criteria. Ordinal logistic regression models explored associations of comorbidity counts with frailty.

Results

Cross-sectional data were from 2473 participants, 57% female, median age 72 (range 40 to 96) years. 518 (21%) participants were classified as frail. Mean (SD) pain score was 5.5 (2.5). Median (IQR) painful comorbidities was 2 (1 to 3) and non-painful 1 (0 to 2). Highest comorbidity frequency: arthritis (66%) and hypertension (38%). Pain was associated with frailty (OR 1.58 (1.52 to 1.64)). Painful comorbidities (aOR 1.64 (1.54 to 1.75) and non-painful comorbidities (aOR 1.31 (1.21 to 1.41)) were both associated with frailty when included in the same multivariable model adjusted for age, sex and BMI.

Conclusions

Painful comorbidities were most strongly associated with frailty, although non-painful comorbidities also contributed. Pain and frailty are interconnected, and this might in part be due to comorbidities or their treatments. These findings provide justification for further research to identify the mechanisms through which pain is involved in frailty and to include pain management in interventions to ameliorate frailty.

Chronic pain in people living with dementia: challenges to recognising and managing pain, and personalising intervention by phenotype

Pain is common in people with dementia, and pain can exacerbate the behavioural and psychological symptoms of dementia. Effective pain management is challenging, not least in people with dementia. Impairments of cognition, communication and abstract thought can make communicating pain unreliable or impossible. It is unclear which biopsychosocial interventions for pain management are effective in people with dementia, and which interventions for behavioural and psychological symptoms of dementia are effective in people with pain. The result is that drugs, physical therapies and psychological therapies might be either underused or overused. People with dementia and pain could be helped by assessment processes that characterise an individual's pain experience and dementia behaviours in a mechanistic manner, phenotyping. Chronic pain management has moved from a 'one size fits all' approach, towards personalised medicine, where interventions recommended for an individual depend upon the key mechanisms underlying their pain, and the relative values they place on benefits and adverse effects. Mechanistic phenotyping through careful personalised evaluation would define the mechanisms driving pain and dementia behaviours in an individual, enabling the formulation of a personalised intervention strategy. Central pain processing mechanisms are particularly likely to be important in people with pain and dementia, and interventions to accommodate and address these may be particularly helpful, not only to relieve pain but also the symptoms of dementia.

Association of pain and risk of falls in community-dwelling adults: a prospective study in the Survey of Health, Ageing and Retirement in Europe (SHARE)

PURPOSE

To investigate the longitudinal associations between pain and falls risks in adults.

METHODS

Prospective cohort study on data from 40,636 community-dwelling adults ≥ 50 years assessed in Wave 5 and 6 in the Survey of Health, Ageing and Retirement in Europe (SHARE). Socio-demographic and clinical information was collected at baseline (Wave 5). At 2-year follow-up (Wave 6), falls in the previous 6 months were recorded. The longitudinal associations between pain intensity, number of pain sites and pain in specific anatomic sites, respectively, and falls risk were analysed by binary logistic regression models; odds ratios (95% confidence intervals) were calculated. All analyses were adjusted for socio-demographic and clinical factors and stratified by sex.

RESULTS

Mean age was 65.8 years (standard deviation 9.3; range 50-103); 22,486 (55.3%) participants were women. At follow-up, 2805 (6.9%) participants reported fall(s) in the previous 6 months. After adjustment, participants with moderate and severe pain at baseline had an increased falls risk at follow-up of 1.35 (1.21-1.51) and 1.52 (1.31-1.75), respectively, compared to those without pain (both p < 0.001); mild pain was not associated with falls risk. Associations between pain intensity and falls risk were greater at younger age (p for interaction < 0.001). Among participants with pain, pain in ≥ 2 sites or all over (multisite pain) was associated with an increased falls risk of 1.29 (1.14-1.45) compared to pain in one site (p < 0.001).

CONCLUSIONS

Moderate, severe and multisite pain were associated with an increased risk of subsequent falls in adults.

Can the Clinical Frailty Scale on admission predict 30-day survival, postoperative complications, and institutionalization in patients with fragility hip fracture? : a cohort study of 1,255 patients

AIMS

We assessed the value of the Clinical Frailty Scale (CFS) in the prediction of adverse outcome after hip fracture.

METHODS

Of 1,577 consecutive patients aged > 65 years with a fragility hip fracture admitted to one institution, for whom there were complete data, 1,255 (72%) were studied. Clinicians assigned CFS scores on admission. Audit personnel routinely prospectively completed the Standardised Audit of Hip Fracture in Europe form, including the following outcomes: 30-day survival; in-hospital complications; length of acute hospital stay; and new institutionalization. The relationship between the CFS scores and outcomes was examined graphically and the visual interpretations were tested statistically. The predictive values of the CFS and Nottingham Hip Fracture Score (NHFS) to predict 30-day mortality were compared using receiver operating characteristic area under the curve (AUC) analysis.

RESULTS

Significant non-linear associations between CFS and outcomes were observed. Risk of death within 30 days rose linearly for CFS 1 to 5, but plateaued for CFS > 5. The incidence of complications and length of stay rose linearly for CFS 1 to 4, but plateaued for CFS > 4. In contrast, the risk of new institutionalization rose linearly for CFS 1 to 8. The AUCs for 30-day mortality for the CFS and NHFS were very similar: CFS AUC 0.63 (95% CI 0.57 to 0.69) and NHFS AUC 0.63 (95% CI 0.57 to 0.69).

CONCLUSION

Use of the CFS may provide useful information on outcomes for fitter patients presenting with hip fracture, but completion of the CFS by the admitting orthopaedic team does not appear successful in distinguishing between higher CFS categories, which define patients with frailty. This makes a strong case for the role of the orthogeriatrician in the early assessment of these patients. Further work is needed to understand why patients assessed as being of mild, moderate, and severe frailty do not result in different outcomes. Cite this article: Bone Joint J 2022;104-B(8):980-986.

Advance care plans in UK care home residents: a service evaluation using a stepped wedge design

Introduction

advance care planning (ACP) in care homes has high acceptance, increases the proportion of residents dying in place and reduces hospital admissions in research. We investigated whether ACP had similar outcomes when introduced during real-world service implementation.

Methods

a service undertaking ACP in Lincoln, UK care homes was evaluated using routine data. Outcomes were proportion of care homes and residents participating in ACP; characteristics of residents choosing/declining ACP and place of death for those with/without ACP. Hospital admissions were analysed using mixed-effects Poisson regression for number of admissions, and a mixed-effects negative binomial model for number of occupied hospital bed days.

Results

About 15/24 (63%) eligible homes supported the service, in which 404/508 (79.5%) participants chose ACP. Residents choosing ACP were older, frailer, more cognitively impaired and malnourished; 384/404 (95%) residents choosing ACP recorded their care home as their preferred place of death: 380/404 (94%) declined cardiopulmonary resuscitation. Among deceased residents, 219/248 (88%) and 33/49 (67%) with and without advance care plan respectively died in their care home (relative risk 1.35, 95% confidence interval [CI] 1.1–1.6, P < 0.001). Hospital admission rates and bed occupancy did not differ after implementation.

Discussion

About 79.5% participants chose ACP. Those doing so were more likely to die at home. Many homes were unwilling or unable to support the service. Hospital admissions were not reduced. Further research should consider how to enlist the support of all homes and to explore why hospital admissions were not reduced.

'It is designed for everybody to find their own level and to improve themselves'; views of older people and instructors of the Falls Management Exercise (FaME) programme

BACKGROUND

Older adults are at increased risk of falls due to ageing, decreased muscle strength and impaired balance. Clinical trials have demonstrated the efficacy and effectiveness of the Falls Management Exercise (FaME) programme in improving functioning and preventing falls. However, programme completion is often low, impacting the potential benefits of FaME.

OBJECTIVE

To explore the barriers and facilitators for participation and completion of the FaME programme from an instructor and participant perspective.

METHODS

Semi-structured interviews were conducted with 20 FaME users and seven Postural Stability Instructors from the East Midlands region of England, UK. Interviews were conducted using a topic guide and explored their views of the programme, intended benefits, reasons for participating, instructor's approach and venue facilities. Data were transcribed verbatim and analysed using thematic analysis. Written informed consent was obtained from all participants and instructors.

RESULTS

Common themes identified by participants and instructors for adherence related to perceived health benefits, psychological well-being, intervention characteristics, cost, instructors' qualities, opportunity to socialise, venue accessibility and facilities. Further factors such as maintaining independence, discipline, relationship with peers and caring responsibilities influenced participants' engagement with the programme. Instructor factors such as progression were also reported as important predictors.

CONCLUSIONS

Instructor and participant factors influence uptake, attendance and adherence of FaME. The findings from this study can inform the development and improvement of additional falls-prevention programmes. It can also guide marketing strategies to promote uptake of exercise-based falls-prevention programmes among older adults.

Multifactorial falls prevention programme compared with usual care in UK care homes for older people: multicentre cluster randomised controlled trial with economic evaluation

OBJECTIVES

To determine the clinical and cost effectiveness of a multifactorial fall prevention programme compared with usual care in long term care homes.

DESIGN

Multicentre, parallel, cluster randomised controlled trial.

SETTING

Long term care homes in the UK, registered to care for older people or those with dementia.

PARTICIPANTS

1657 consenting residents and 84 care homes. 39 were randomised to the intervention group and 45 were randomised to usual care.

INTERVENTIONS

Guide to Action for Care Homes (GtACH): a multifactorial fall prevention programme or usual care.

MAIN OUTCOME MEASURES

Primary outcome measure was fall rate at 91-180 days after randomisation. The economic evaluation measured health related quality of life using quality adjusted life years (QALYs) derived from the five domain five level version of the EuroQoL index (EQ-5D-5L) or proxy version (EQ-5D-5L-P) and the Dementia Quality of Life utility measure (DEMQOL-U), which were self-completed by competent residents and by a care home staff member proxy (DEMQOL-P-U) for all residents (in case the ability to complete changed during the study) until 12 months after randomisation. Secondary outcome measures were falls at 1-90, 181-270, and 271-360 days after randomisation, Barthel index score, and the Physical Activity Measure-Residential Care Homes (PAM-RC) score at 91, 180, 270, and 360 days after randomisation.

RESULTS

Mean age of residents was 85 years. 32% were men. GtACH training was delivered to 1051/1480 staff (71%). Primary outcome data were available for 630 participants in the GtACH group and 712 in the usual care group. The unadjusted incidence rate ratio for falls between 91 and 180 days was 0.57 (95% confidence interval 0.45 to 0.71, P<0.001) in favour of the GtACH programme (GtACH: six falls/1000 residents v usual care: 10 falls/1000). Barthel activities of daily living indices and PAM-RC scores were similar between groups at all time points. The incremental cost was £108 (95% confidence interval -£271.06 to 487.58), incremental QALYs gained for EQ-5D-5L-P was 0.024 (95% confidence interval 0.004 to 0.044) and for DEMQOL-P-U was 0.005 (-0.019 to 0.03). The incremental costs per EQ-5D-5L-P and DEMQOL-P-U based QALY were £4544 and £20 889, respectively.

CONCLUSIONS

The GtACH programme was associated with a reduction in fall rate and cost effectiveness, without a decrease in activity or increase in dependency.

TRIAL REGISTRATION

ISRCTN34353836.

How quality improvement collaboratives work to improve healthcare in care homes: a realist evaluation

BACKGROUND

Quality improvement collaboratives (QICs) bring together multidisciplinary teams in a structured process to improve care quality. How QICs can be used to support healthcare improvement in care homes is not fully understood.

METHODS

A realist evaluation to develop and test a programme theory of how QICs work to improve healthcare in care homes. A multiple case study design considered implementation across 4 sites and 29 care homes. Observations, interviews and focus groups captured contexts and mechanisms operating within QICs. Data analysis classified emerging themes using context-mechanism-outcome configurations to explain how NHS and care home staff work together to design and implement improvement.

RESULTS

QICs will be able to implement and iterate improvements in care homes where they have a broad and easily understandable remit; recruit staff with established partnership working between the NHS and care homes; use strategies to build relationships and minimise hierarchy; protect and pay for staff time; enable staff to implement improvements aligned with existing work; help members develop plans in manageable chunks through QI coaching; encourage QIC members to recruit multidisciplinary support through existing networks; facilitate meetings in care homes and use shared learning events to build multidisciplinary interventions stepwise. Teams did not use measurement for change, citing difficulties integrating this into pre-existing and QI-related workload.

CONCLUSIONS

These findings outline what needs to be in place for health and social care staff to work together to effect change. Further research needs to consider ways to work alongside staff to incorporate measurement for change into QI.

'Real world' effectiveness of the Falls Management Exercise (FaME) programme: an implementation study

BACKGROUND

Falls incidence increases with age alongside declines in strength and balance. Clinical trials show that the Falls Management Exercise (FaME) programme improves strength and balance, which can reduce falls and improve physical functioning.

OBJECTIVE

To determine if the clinical trial efficacy of FaME translates into effectiveness in non-research settings.

DESIGN AND SETTING

An implementation study of FaME in 10 local authorities across the East Midlands region of England.

SUBJECTS

Adults aged 65 and over enrolled on a FaME programme.

METHOD

Anonymised outcome data collected by the FaME providers were compared at baseline, end of programme and 6 months follow-up using univariate and multivariate analyses.

RESULTS

For 348 adults enrolled in programmes and analysed, the mean age was 76.8, 73% were female and 143 (41%) completed ≥75% of classes. Overall confidence in balance, fear of falling, functional reach and timed-up-and-go (all P < 0.001), and turn 180° (P = 0.008) improved significantly at programme completion versus baseline, but improvements were not maintained 6 months later. Falls risk (FRAT score) and total minutes of physical activity did not change significantly though minutes of strength and balance activity increased by 55% at programme completion and was maintained at 6 months. The falls incidence rate ratio (IRR) was non-significantly lower at programme completion (IRR 0.76, 95% Confidence Interval (CI) 0.48,1.21) and follow-up (IRR 0.82 95% CI 0.48,1.39) versus baseline.

CONCLUSIONS

There is modest translation of FaME efficacy into effectiveness, but not all effects persist after completion. Strategies to aid adherence and exercise maintenance are important to maximise benefits.

Optimal management of older people with frailty non-weight bearing after lower limb fracture: a scoping review

Background

Patients with lower limb fractures who are non-weight bearing are at risk of the complications of the associated immobility and disability, particularly people with frailty, but there is lack of clarity about what constitutes optimal care for such patients. A scoping literature review was conducted to explore what evidence is available for the management of this patient group.

Methods

MEDLINE (PubMed) CINAHL, EMBASE and the Cochrane databases of published literature and the HMIC and SIGLE sites for grey literature were searched for primary research studies and expert reports, using an iterative approach initially including the key term ‘non-weight bearing’. All study types were included. Analysis was by narrative synthesis.

Results

No papers were identified from a search using the key phrase ‘non-weight bearing’. With this term removed, 11 indirectly relevant articles on lower limb fractures were retrieved from the searches of the electronic databases comprising three observational studies, five non-systematic review articles, a systematic review, an opinion piece and a survey of expert opinion that had relevance to restricted weight bearing patients. The observational studies indicated depression, cognition and nutrition affect outcome and hence have indirect relevance to management. The non-systematic reviews articles emphasised the importance of maintaining strength and range of movement during immobilisation and advised an orthogeriatric model of care. Fourteen UK and 97 non-UK guidelines relevant to fragility fractures, falls and osteoporosis management were found in the grey literature, but none made specific recommendations regarding the management of any period of non-weight bearing.

Discussion

These findings provide a summary of the evidence base that can be used in the development of a clinical guideline for these patients but is not sufficient. We propose that, a guideline should be developed for these patients using an expert consensus process.

Management of patients admitted to hospital with acute vertebral fragility fractures: a modified Delphi study

INTRODUCTION

Acute vertebral fragility fracture requiring hospital admission is common, painful and disabling. No comprehensive clinical guideline for their care exists. To support the development of such a guideline, we sought the views of experts in the field.

METHODS

A modified Delphi study was used. A total of 70 statements were presented, using an online platform, over three consensus-seeking rounds, to participants with experience in the hospital care of patients with acute vertebral fragility fractures from UK-based specialist societies. Participants rated the level of their agreement with each statement on a 5-point Likert scale. Consensus was defined at 70% of respondents choosing either agree/strongly agree or disagree/strong disagree. Over the first two rounds, statements not reaching consensus were modified in subsequent rounds, and new statements proposed by participants and agreed by the research team could be added.

RESULTS

There were 71 participants in the first round, 37 in the second round and 28 (most of whom were geriatricians) in the third round. Consensus was reached in 52 statements covering fracture diagnosis, second-line imaging, organisation of hospital care, pain management and falls and bone health assessment. Consensus was not achieved for whether vertebral fragility fractures should be managed in a specific clinical area.

DISCUSSION

These findings provide the basis for the development of clinical guidelines and quality improvement initiatives. They also help to justify research into the merits of managing acute vertebral fragility fracture patients in a specific clinical area.

Community-based complex interventions to sustain independence in older people, stratified by frailty: a protocol for a systematic review and network meta-analysis

INTRODUCTION

Maintaining independence is a primary goal of community health and care services for older people, but there is currently insufficient guidance about which services to implement. Therefore, we aim to synthesise evidence on the effectiveness of community-based complex interventions to sustain independence for older people, including the effect of frailty, and group interventions to identify the best configurations.

METHODS AND ANALYSIS

Systematic review and network meta-analysis (NMA). We will include randomised controlled trials (RCTs) and cluster RCTs of community-based complex interventions to sustain independence for older people living at home (mean age ≥65 years), compared with usual care or another complex intervention. We will search MEDLINE (1946 to September 2020), Embase (1947 to September 2020), CINAHL (1981 to September 2020), PsycINFO (1806 to September 2020), CENTRAL and clinical trial registries from inception to September 2020, without date/language restrictions, and scan included papers' reference lists. Main outcomes were: living at home, activities of daily living (basic/instrumental), home-care services usage, hospitalisation, care home admission, costs and cost effectiveness. Additional outcomes were: health status, depression, loneliness, falls and mortality. Interventions will be coded, summarised and grouped. An NMA using a multivariate random-effects model for each outcome separately will determine the relative effects of different complex interventions. For each outcome, we will produce summary effect estimates for each pair of treatments in the network, with 95% CI, ranking plots and measures, and the borrowing of strength statistic. Inconsistency will be examined using a 'design-by-treatment interaction' model. We will assess risk of bias (Cochrane tool V.2) and certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation for NMA approach.

ETHICS AND DISSEMINATION

This research will use aggregated, anonymised, published data. Findings will be reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance. They will be disseminated to policy-makers, commissioners and providers, and via conferences and scientific journals.

PROSPERO REGISTRATION NUMBER

CRD42019162195.

Care homes, their communities, and resilience in the face of the COVID-19 pandemic: interim findings from a qualitative study

BACKGROUND

From late February 2020, English care homes rapidly adapted their practices in response to the COVID-19 pandemic. In addition to accommodating new guidelines and policies, staff had to adjust to rapid reconfiguration of services external to the home that they would normally depend upon for support. This study examined the complex interdependencies of support as staff responded to COVID-19. The aim was to inform more effective responses to the ongoing pandemic, and to improve understanding of how to work with care home staff and organisations after the pandemic has passed.

METHODS

Ten managers of registered care homes in the East Midlands of England were interviewed by videoconference or phone about their experiences of the crisis from a structured organisational perspective. Analysis used an adapted organisational framework analysis approach with a focus on social ties and interdependencies between organisations and individuals.

RESULTS

Three key groups of interdependencies were identified: care processes and practice; resources; and governance. Care home staff had to deliver care in innovative ways, making high stakes decisions in circumstances defined by: fluid ties to organisations outside the care home; multiple, sometimes conflicting, sources of expertise and information; and a sense of deprioritisation by authorities. Organisational responses to the pandemic by central government resulted in resource constraints and additional work, and sometimes impaired the ability of staff and managers to make decisions. Local communities, including businesses, third-sector organisations and individuals, were key in helping care homes overcome challenges. Care homes, rather than competing, were found to work together to provide mutual support. Resilience in the system was a consequence of dedicated and resourceful staff using existing local networks, or forging new ones, to overcome barriers to care.

CONCLUSIONS

This study identified how interdependency between care home organisations, the surrounding community, and key statutory and non-statutory organisations beyond their locality, shaped decision making and care delivery during the pandemic. Recognising these interdependencies, and the expertise shown by care home managers and staff as they navigate them, is key to providing effective healthcare in care homes as the pandemic progresses, and as the sector recovers afterwards.

The clinical usefulness of muscle mass and strength measures in older people: a systematic review

Background

sarcopenia is the loss of muscle mass and quality and is diagnosed using measures of muscle strength, size and mass. We evaluated the literature on whether sarcopenia measures are predictive of motor outcomes in older people in clinical settings.

Methods

electronic databases (MEDLINE Ovid, EMBASE, CINAHL and Web of Science) were searched for articles on measures of muscle mass, volume, thickness or strength, in older people in clinical settings, which reported cross-sectional or longitudinal associations with motor outcomes. Clinical cohorts included geriatric medical inpatients and outpatients, patients with hip fracture, geriatric rehabilitation and care home residents. Motor outcomes were mobility, falls, balance and activities of daily living (ADL). Due to high study heterogeneity, standardised mean differences were used to compare strength of associations.

Results

in total, 83 articles were identified. The most frequently studied measures were grip strength (47 studies), knee extension strength (21 studies) and bioelectrical impedance analysis (18 studies). Handgrip strength (HGS) had evidence for cross-sectional associations with mobility (14 of 16 studies, 2,088 participants), balance (6 of 6 studies, 1,177 participants) and ADL independence (10 of 11 studies, 3,228 participants), and evidence of longitudinal associations with mobility (3 of 3 studies, 883 participants) and ADL independence (7 of 10 studies, 1,511 participants). There was no conclusive evidence for association with falls.

Conclusions

HS was the most studied measure and was associated with mobility, balance and ADL outcomes. There was a paucity of studies, particularly with longitudinal follow-up, measuring muscle mass, volume or thickness using gold-standard approaches.

Exercise interventions for older adults: A systematic review of meta-analyses

BACKGROUND

The evidence concerning which physical exercise characteristics are most effective for older adults is fragmented. We aimed to characterize the extent of this diversity and inconsistency and identify future directions for research by undertaking a systematic review of meta-analyses of exercise interventions in older adults.

METHODS

We searched the Cochrane Database of Systematic Reviews, PsycInfo, MEDLINE, Embase, CINAHL, AMED, SPORTDiscus, and Web of Science for articles that met the following criteria: (1) meta-analyses that synthesized measures of improvement (e.g., effect sizes) on any outcome identified in studies of exercise interventions; (2) participants in the studies meta-analyzed were adults aged 65+ or had a mean age of 70+; (3) meta-analyses that included studies of any type of exercise, including its duration, frequency, intensity, and mode of delivery; (4) interventions that included multiple components (e.g., exercise and cognitive stimulation), with effect sizes that were computed separately for the exercise component; and (5) meta-analyses that were published in any year or language. The characteristics of the reviews, of the interventions, and of the parameters improved through exercise were reported through narrative synthesis. Identification of the interventions linked to the largest improvements was carried out by identifying the highest values for improvement recorded across the reviews. The study included 56 meta-analyses that were heterogeneous in relation to population, sample size, settings, outcomes, and intervention characteristics.

RESULTS

The largest effect sizes for improvement were found for resistance training, meditative movement interventions, and exercise-based active videogames.

CONCLUSION

The review identified important gaps in research, including a lack of studies investigating the benefits of group interventions, the characteristics of professionals delivering the interventions associated with better outcomes, and the impact of motivational strategies and of significant others (e.g., carers) on intervention delivery and outcomes.

Polypharmacy, benzodiazepines, and antidepressants, but not antipsychotics, are associated with increased falls risk in UK care home residents: a prospective multi-centre study

Aim

To explore the link between polypharmacy, psychotropic medications, and falls risk in a cohort of UK care home residents.

Findings

Polypharmacy and psychotropic drugs are predictive of falls in UK care home residents.

Message

Deprescribing interventions relating to psychotropic drugs should continue to be encouraged.

Purpose

Falls and polypharmacy are both common in care home residents. Deprescribing of medications in residents with increased falls risk is encouraged. Psychotropic medications are known to increase falls risk in older adults. These drugs are often used in care home residents for depression, anxiety, and behavioural and psychological symptoms of dementia. However, a few studies have explored the link between polypharmacy, psychotropic medications, and falls risk in care home residents.

Methods

This was a prospective cohort study of residents from 84 UK care homes. Data were collected from residents’ care records and medication administration records. Age, diagnoses, gender, number of medications, and number of psychotropic medications were collected at baseline and residents were monitored over three months for occurrence of falls. Logistic regression models were used to assess the effect of multiple medications and psychotropic medication on falls whilst adjusting for confounders.

Results

Of the 1655 participants, mean age 85 (SD 8.9) years, 67.9% female, 519 (31%) fell in 3 months. Both the total number of regular drugs prescribed and taking ≥ 1 regular psychotropic medication were independent risk factors for falling (adjusted odds ratio (OR) 1.06 (95% CI 1.03–1.09, p < 0.01) and 1.39 (95% CI 1.10–1.76, p < 0.01), respectively). The risk of falls was higher in those taking antidepressants (p < 0.01) and benzodiazepines (p < 0.01) but not antipsychotics (p > 0.05).

Conclusion

In UK care homes, number of medications and psychotropic medications (particularly antidepressants and benzodiazepines) predicted falls. This information can be used to inform prescribing and deprescribing decisions.

Ethnic disparity in access to the memory assessment service between South Asian and white British older adults in the United Kingdom: A cohort study

BACKGROUND

Equality of access to memory assessment services by older adults from ethnic minorities is both an ethical imperative and a public health priority.

OBJECTIVE

To investigate whether timeliness of access to memory assessment service differs between older people of white British and South Asian ethnicity.

DESIGN

Longitudinal cohort.

SETTING

Nottingham Memory Study; outpatient secondary mental healthcare.

SUBJECTS

Our cohort comprised 3654 white British and 32 South Asian older outpatients.

METHODS

The criterion for timely access to memory assessment service was set at 90 days from referral. Relationships between ethnicity and likelihood of timely access to memory assessment service were analysed using binary logistic regression. Analyses were adjusted for socio-demographic factors, deprivation and previous access to rapid response mental health services.

RESULTS

Among white British outpatients, 2272 people (62.2%) achieved timely access to memory assessment service. Among South Asian outpatients, fourteen people (43.8%) achieved timely access to memory assessment service. After full adjustment, South Asian outpatients had a 0.47-fold reduced likelihood of timely access, compared to white British outpatients (odds ratio 0.47, 95% confidence interval 0.23-0.95, P value = .035). The difference became non-significant when restricting analyses to outpatients reporting British nationality or English as first language. Older age, lower index of deprivation and previous access to rapid response mental health services were associated with reduced likelihood of timely access, while gender was not.

CONCLUSIONS

In a UK mental healthcare service, older South Asian outpatients are less likely to access dementia diagnostic services in a timely way, compared to white British outpatients.

The modified functional comorbidity index performed better than the Charlson index and original functional comorbidity index in predicting functional outcome in geriatric rehabilitation: a prospective observational study

Background

In the inpatient rehabilitation of older patients, estimating to what extent the patient may functionally recover (functional prognosis), is important to plan the rehabilitation programme and aid discharge planning. Comorbidity is very common in older patients. However, the role of comorbidity in making a functional prognosis is not clearly defined. The aim of this study was to investigate a modified and weighted Functional Comorbidity Index (w-FCI) in relation to functional recovery and compare its predictive performance with that of the Charlson comorbidity index (CCI) and the original Functional Comorbidity Index (FCI).

Methods

The COOPERATION study (Comorbidity and Outcomes of Older Patients Evaluated in RehabilitATION) is a prospective observational cohort study. Data of patients that were admitted in an inpatient geriatric rehabilitation facility in the UK between January and September 2017, were collected. The outcome measures were: the Elderly Mobility Scale (EMS) and Barthel index (BI) at discharge, EMS gain/day and BI gain/day. Baseline comorbidity was assessed using the CCI, the FCI and the w-FCI. Correlations, receiver operating curves (ROC), and multiple linear regression analyses were performed. The models were adjusted for age, gender and EMS or BI on admission.

Results

In total, 98 patients (mean age 82 years; 37% male) were included. The areas under the ROC curves of the w-FCI (EMS at discharge: 0.72, EMS gain/day: 0.72, BI at discharge: 0.66 and BI gain/day: 0.60) were higher than for the CCI (0.50, 0.53, 0.49, 0.44 respectively) and FCI (0.65, 0.55, 0.60, 0.49 respectively). The w-FCI was independently associated with EMS at discharge (20.7% of variance explained (PVE), p < 0.001), EMS gain/day (11.2PVE, p < 0.001), and BI at discharge (18.3 PVE, p < 0.001). The FCI was only associated with EMS gain/day (3.9 PVE, p < 0.05). None of the comorbidity indices contributed significantly to BI gain/day (w-FCI: 2.4 PVE, p > 0.05).

Conclusions

The w-FCI was predictive of mobility & function at discharge and mobility gain per day, and outperformed the original FCI and the CCI. The w-FCI could be useful in assessing comorbidity in a personalised way and aid functional prognosis at the start of rehabilitation.

Investigating musculoskeletal health and wellbeing; a cohort study protocol

Background

In an ageing population, pain, frailty and disability frequently coexist across a wide range of musculoskeletal diagnoses, but their associations remain incompletely understood. The Investigating Musculoskeletal Health and Wellbeing (IMH&W) study aims to measure and characterise the development and progression of pain, frailty and disability, and to identify discrete subgroups and their associations. The survey will form a longitudinal context for nested research, permitting targeted recruitment of participants for qualitative, observational and interventional studies; helping to understand recruitment bias in clinical studies; and providing a source cohort for cohort randomised controlled trials.

Methods

IMH&W will comprise a prospective cohort of 10,000 adults recruited through primary and secondary care, and through non-clinical settings. Data collection will be at baseline, and then through annual follow-ups for 4 years. Questionnaires will address demographic characteristics, pain severity (0–10 Numerical Rating Scale), pain distribution (reported on a body Manikin), pain quality (McGill Pain Questionnaire), central aspects of pain (CAP-Knee), frailty and disability (based on Fried criteria and the FRAIL questionnaire), and fracture risk. Baseline characteristics, progression and associations of frailty, pain and disability will be determined. Discrete subgroups and trajectories will be sought by latent class analysis. Recruitment bias will be explored by comparing participants in nested studies with the eligible IMH&W population.

Discussion

IMH&W will elucidate associations and progression of pain, frailty and disability. It will enable identification of people at risk of poor musculoskeletal health and wellbeing outcomes who might be suitable for specific interventions, and facilitate generalisation and comparison of research outcomes between target populations. The study will benefit from a large sample size and will recruit from diverse regions across the UK. Purposive recruitment will enrich the cohort with people with MSK problems with high representation of elderly and unwell people.

Trial registration

Clinicaltrials.gov NCT03696134. Date of Registration: 04 October 2018.

The Nottingham Spinal Health (NoSH) Study: a cohort study of patients hospitalised with vertebral fragility fractures

Patients hospitalised with vertebral fragility fractures were elderly, multimorbid and frail and lead to poor outcomes. Their hospital treatment needs to consider this alongside their acute fracture. A systematic organised model of care, such as an adaptation of orthogeriatric hip fracture care, will offer a more holistic approach potentially improving their outcomes.

PURPOSE

Patients admitted to hospital with vertebral fragility fractures are elderly and have complex care needs who may benefit from specialist multidisciplinary input. To date, their characteristics and outcomes have not been reported sufficiently. This study aims to justify such a service.

METHODS

Patients admitted with an acute vertebral fragility fracture over 12 months were prospectively recruited from a university hospital in England. Data were collected soon after their admission, at discharge from hospital and 6 months after their hospital discharge on their characteristics, pain, physical functioning, and clinical outcomes.

RESULTS

Data from 90 participants were analysed. They were mainly elderly (mean age 79.7 years), multimorbid (69% had ≥ 3 comorbid condition), frail (56% had a Clinical Frailty Scale score ≥ 5), cognitively impaired (54% had a MoCA score of < 23) and at high risk of falls (65% had fallen ≥ 2 in the previous year). Eighteen percent died at 6 months. At 6 months post-hospital discharge, 12% required a new care home admission, 37% still reported their pain to be severe and physical functioning was worse compared with their preadmission state.

CONCLUSION

Patients hospitalised with vertebral fragility fractures were elderly, multimorbid, frail and are susceptible to persistent pain and disability. Their treatment in hospital needs to consider this alongside their acute fracture. A systematic organised model of care, such as an adaptation of orthogeriatric hip fracture care, will offer a more holistic approach potentially improving their outcomes.

Measuring health-related quality of life of care home residents: comparison of self-report with staff proxy responses

Introduction

care home residents are often unable to complete health-related quality of life questionnaires for themselves because of prevalent cognitive impairment. This study compared care home resident and staff proxy responses for two measures, the EQ-5D-5L and HowRU.

Methods

a prospective cohort study recruited residents ≥60 years across 24 care homes who were not receiving short stay, respite or terminal care. Resident and staff proxy EQ-5D-5L and HowRu responses were collected monthly for 3 months. Weighted kappa statistics and intra-class correlation coefficients (ICCs) adjusted for clustering at the care home level were used to measure agreement between resident and proxies for each time point. The effect of staff and resident baseline variables on agreement was considered using a multilevel mixed effect regression model.

Results

117, 109 and 104 matched pairs completed the questionnaires at 1, 2 and 3 months, respectively. When clustering was controlled for, agreement between resident and staff proxy EQ-5D-5L responses was fair for mobility (ICC: 0.29) and slight for all other domains (ICC ≤ 0.20). EQ-5D Index and Quality-Adjusted Life Year scores (proxy scores higher than residents) showed better agreement than EQ-5D-VAS (residents scores higher than proxy). HowRU showed only slight agreement (ICC ≤ 0.20) between residents and proxies. Staff and resident characteristics did not influence level of agreement for either index.

Discussion

the levels of agreement for EQ-5D-5L and HowRU raise questions about their validity in this population.

Role of comprehensive geriatric assessment in healthcare of older people in UK care homes: realist review

OBJECTIVES

Comprehensive geriatric assessment (CGA) may be a way to deliver optimal care for care home residents. We used realist review to develop a theory-driven account of how CGA works in care homes.

DESIGN

Realist review.

SETTING

Care homes.

METHODS

The review had three stages: first, interviews with expert stakeholders and scoping of the literature to develop programme theories for CGA; second, iterative searches with structured retrieval and extraction of the literature; third, synthesis to refine the programme theory of how CGA works in care homes.We used the following databases: Medline, CINAHL, Scopus, PsychInfo, PubMed, Google Scholar, Greylit, Cochrane Library and Joanna Briggs Institute.

RESULTS

130 articles informed a programme theory which suggested CGA had three main components: structured comprehensive assessment, developing a care plan and working towards patient-centred goals. Each of these required engagement of a multidisciplinary team (MDT). Most evidence was available around assessment, with tension between structured assessment led by a single professional and less structured assessment involving multiple members of an MDT. Care planning needed to accommodate visiting clinicians and there was evidence that a core MDT often used care planning as a mechanism to seek external specialist support. Goal-setting processes were not always sufficiently patient-centred and did not always accommodate the views of care home staff. Studies reported improved outcomes from CGA affecting resident satisfaction, prescribing, healthcare resource use and objective measures of quality of care.

CONCLUSION

The programme theory described here provides a framework for understanding how CGA could be effective in care homes. It will be of use to teams developing, implementing or auditing CGA in care homes. All three components are required to make CGA work-this may explain why attempts to implement CGA by interventions focused solely on assessment or care planning have failed in some long-term care settings.

TRIAL REGISTRATION NUMBER

CRD42017062601.

Personal growth and development in old age-a clinician's perspective

This invited article is drawn from the content of the Marjory Warren Lecture given by John Gladman at the British Geriatrics Society Spring Meeting in 2018, entitled 'The Meaning of Life Expectancy'.

Measuring health-related quality of life of care home residents, comparison of self-report with staff proxy responses for EQ-5D-5L and HowRu: protocol for assessing proxy reliability in care home outcome testing

INTRODUCTION

Research into interventions to improve health and well-being for older people living in care homes is increasingly common. Health-related quality of life (HRQoL) is frequently used as an outcome measure, but collecting both self-reported and proxy HRQoL measures is challenging in this setting. This study will investigate the reliability of UK care home staff as proxy respondents for the EQ-5D-5L and HowRu measures.

METHODS AND ANALYSIS

This is a prospective cohort study of a subpopulation of care home residents recruited to the larger Proactive Healthcare for Older People in Care Homes (PEACH) study. It will recruit residents ≥60 years across 24 care homes and not receiving short stay or respite care. The sample size is 160 participants. Resident and care home staff proxy EQ-5D-5L and HowRu responses will be collected monthly for 3 months. Weighted kappa statistics and intraclass correlation adjusted for clustering at the care home level will be used to measure agreement between resident and proxy responses. The extent to which staff variables (gender, age group, length of time caring, role, how well they know the resident, length of time working in care homes and in specialist gerontological practice) influence the level of agreement between self-reported and proxy responses will be considered using a multilevel mixed-effect regression model.

ETHICS AND DISSEMINATION

The PEACH study protocol was reviewed by the UK Health Research Authority and University of Nottingham Research Ethics Committee and was determined to be a service development project. We will publish this study in a peer-reviewed journal with international readership and disseminate it through relevant national stakeholder networks and specialist societies.

Optimal healthcare delivery to care homes in the UK: a realist evaluation of what supports effective working to improve healthcare outcomes

INTRODUCTION

care home residents have high healthcare needs not fully met by prevailing healthcare models. This study explored how healthcare configuration influences resource use.

METHODS

a realist evaluation using qualitative and quantitative data from case studies of three UK health and social care economies selected for differing patterns of healthcare delivery to care homes. Four homes per area (12 in total) were recruited. A total of 239 residents were followed for 12 months to record resource-use. Overall, 181 participants completed 116 interviews and 13 focus groups including residents, relatives, care home staff, community nurses, allied health professionals and General Practitioners.

RESULTS

context-mechanism-outcome configurations were identified explaining what supported effective working between healthcare services and care home staff: (i) investment in care home-specific work that legitimises and values work with care homes; (ii) relational working which over time builds trust between practitioners; (iii) care which 'wraps around' care homes; and (iv) access to specialist care for older people with dementia. Resource use was similar between sites despite differing approaches to healthcare. There was greater utilisation of GP resource where this was specifically commissioned but no difference in costs between sites.

CONCLUSION

activities generating opportunities and an interest in healthcare and care home staff working together are integral to optimal healthcare provision in care homes. Outcomes are likely to be better where: focus and activities legitimise ongoing contact between healthcare staff and care homes at an institutional level; link with a wider system of healthcare; and provide access to dementia-specific expertise.

Chair based exercise in community settings: a cluster randomised feasibility study

Background

Some older people who find standard exercise programmes too strenuous may be encouraged to exercise while remaining seated - chair based exercises (CBE). We previously developed a consensus CBE programme (CCBE) following a modified Delphi process. We firstly needed to test the feasibility and acceptability of this treatment approach and explore how best to evaluate it before undertaking a definitive trial.

Methods

A feasibility study with a cluster randomised controlled trial component was undertaken to 1. Examine the acceptability, feasibility and tolerability of the intervention and 2. Assess the feasibility of running a trial across 12 community settings (4 day centres, 4 care homes, 4 community groups). Centres were randomised to either CCBE, group reminiscence or usual care. Outcomes were collected to assess the feasibility of the trial parameters: level of recruitment interest and eligibility, randomisation, adverse events, retention, completion of health outcomes, missing data and delivery of the CCBE. Semi- structured interviews were conducted with participants and care staff following the intervention to explore acceptability.

Results

48% (89 out of 184 contacted) of eligible centres were interested in participating with 12 recruited purposively. 73% (94) of the 128 older people screened consented to take part with 83 older people then randomised following mobility testing. Recruitment required greater staffing levels and resources due to 49% of participants requiring a consultee declaration. There was a high dropout rate (40%) primarily due to participants no longer attending the centres. The CCBE intervention was delivered once a week in day centres and community groups and twice a week in care homes. Older people and care staff found the CCBE intervention largely acceptable.

Conclusion

There was a good level of interest from centres and older people and the CCBE intervention was largely welcomed. The trial design and governance procedures would need to be revised to maximise recruitment and retention. If the motivation for a future trial is physical health then this study has identified that further work to develop the CCBE delivery model is warranted to ensure it can be delivered at a frequency to elicit physiological change. If the motivation for a future trial is psychological outcomes then this study has identified that the current delivery model is feasible.

Trial registration

ISRCTN27271501. Date registered: 30/01/2018.

Electronic supplementary material

The online version of this article (10.1186/s12877-018-0769-4) contains supplementary material, which is available to authorized users.

A development study and randomised feasibility trial of a tailored intervention to improve activity and reduce falls in older adults with mild cognitive impairment and mild dementia

Background

People with dementia progressively lose abilities and are prone to falling. Exercise- and activity-based interventions hold the prospect of increasing abilities, reducing falls, and slowing decline in cognition. Current falls prevention approaches are poorly suited to people with dementia, however, and are of uncertain effectiveness. We used multiple sources, and a co-production approach, to develop a new intervention, which we will evaluate in a feasibility randomised controlled trial (RCT), with embedded adherence, process and economic analyses.

Methods

We will recruit people with mild cognitive impairment or mild dementia from memory assessment clinics, and a family member or carer. We will randomise participants between a therapy programme with high intensity supervision over 12 months, a therapy programme with moderate intensity supervision over 3 months, and brief falls assessment and advice as a control intervention. The therapy programmes will be delivered at home by mental health specialist therapists and therapy assistants. We will measure activities of daily living, falls and a battery of intermediate and distal health status outcomes, including activity, balance, cognition, mood and quality of life. The main aim is to test recruitment and retention, intervention delivery, data collection and other trial processes in advance of a planned definitive RCT. We will also study motivation and adherence, and conduct a process evaluation to help understand why results occurred using mixed methods, including a qualitative interview study and scales measuring psychological, motivation and communication variables. We will undertake an economic study, including modelling of future impact and cost to end-of-life, and a social return on investment analysis.

Discussion

In this study, we aim to better understand the practicalities of both intervention and research delivery, and to generate substantial new knowledge on motivation, adherence and the approach to economic analysis. This will enable us to refine a novel intervention to promote activity and safety after a diagnosis of dementia, which will be evaluated in a definitive randomised controlled trial.

Trial registration

ClinicalTrials.gov: NCT02874300; ISRCTN 10550694.

Characteristics and outcomes of hospitalised patients with vertebral fragility fractures: a systematic review

Background

the complex management for patients presenting to hospital with vertebral fragility fractures provides justification for the development of specific services for them. A systematic review was undertaken to determine the incidence of hospital admission, patient characteristics and health outcomes of vertebral fragility fracture patients to inform the development of such a service.

Methods

non-randomised studies of vertebral fragility fracture in hospital were included. Searches were conducted using electronic databases and citation searching of the included papers.

Results

a total of 19 studies were included. The incidence of hospital admission varied from 2.8 to 19.3 per 10,000/year. The average patient age was 81 years, the majority having presented with a fall. A diagnosis of osteoporosis or previous fragility fracture was reported in around one-third of patients. Most patients (75% men and 78% women) had five or more co-pathologies. Most patients were managed non-operatively with a median hospital length of stay of 10 days. One-third of patients were started on osteoporosis treatment. Inpatient and 1-year mortality was between 0.9 and 3.5%, and 20 and 27%, respectively, between 34 and 50% were discharged from hospital to a care facility. Many patients were more dependent with activities of daily living on discharge compared to their pre-admission level. Older age and increasing comorbidities was associated with longer hospital stay and higher mortality.

Conclusion

these findings indicate that specific hospital services for patients with vertebral fragility fractures should take into consideration local hospitalisation rates for the condition, and should be multifaceted-providing access to diagnostic, therapeutic, surgical and rehabilitation interventions.

Using comprehensive geriatric assessment for quality improvements in healthcare of older people in UK care homes: protocol for realist review within Proactive Healthcare of Older People in Care Homes (PEACH) study

INTRODUCTION

Care home residents are relatively high users of healthcare resources and may have complex needs. Comprehensive geriatric assessment (CGA) may benefit care home residents and improve efficiency of care delivery. This is an approach to care in which there is a thorough multidisciplinary assessment (physical and mental health, functioning and physical and social environments) and a care plan based on this assessment, usually delivered by a multidisciplinary team. The CGA process is known to improve outcomes for community-dwelling older people and those in receipt of hospital care, but less is known about its efficacy in care home residents.

METHODS AND ANALYSIS

Realist review was selected as the most appropriate method to explore the complex nature of the care home setting and multidisciplinary delivery of care. The aim of the realist review is to identify and characterise a programme theory that underpins the CGA intervention. The realist review will extract data from research articles which describe the causal mechanisms through which the practice of CGA generates outcomes. The focus of the intervention is care homes, and the outcomes of interest are health-related quality of life and satisfaction with services; for both residents and staff. Further outcomes may include appropriate use of National Health Service services and resources of older care home residents. The review will proceed through three stages: (1) identifying the candidate programme theories that underpin CGA through interviews with key stakeholders, systematic search of the peer-reviewed and non-peer-reviewed evidence, (2) identifying the evidence relevant to CGA in UK care homes and refining the programme theories through refining and iterating the systematic search, lateral searches and seeking further information from study authors and (3) analysis and synthesis of evidence, involving the testing of the programme theories.

ETHICS AND DISSEMINATION

The PEACH project was identified as service development following submission to the UK Health Research Authority and subsequent review by the University of Nottingham Research Ethics Committee. The study protocols have been reviewed as part of good governance by the Nottinghamshire Healthcare Foundation Trust. We aim to publish this realist review in a peer-reviewed journal with international readership. We will disseminate findings to public and stakeholders using knowledge mobilisation techniques. Stakeholders will include the Quality Improvement Collaboratives within PEACH study. National networks, such as British Society of Gerontology and National Care Association will be approached for wider dissemination.

TRIAL REGISTRATION NUMBER

The realist review has been registered on International Prospective Register of Systematic Reviews (PROSPERO 2017: CRD42017062601).

Challenges and opportunities in understanding dementia and delirium in the acute hospital

In an Essay, Andrew Jackson and colleagues discuss challenges in the diagnosis and management of older people with dementia and delirium in acute hospitals.

Description of an Occupational Therapy Intervention Aimed at Improving Outdoor Mobility

After a stroke people can find outdoor mobility difficult, but a targeted occupational therapy intervention has been shown to help people to get out of the house more often. This study describes the intervention.

The occupational therapists who provided the intervention kept records of the number and duration of therapy sessions, the goal of therapy and the activities undertaken. As part of the trial, functional and mobility outcome assessments were completed by the participants 4 and 10 months after recruitment and were used to compare the goals set with the goals achieved and the mobility performance.

Eighty-six participants were randomised to, and 78 received, the intervention. They received a median of 6 (mean 4.7, SD 1.9) sessions, with an average of 40 minutes per session. Sixty (77%) of the participants achieved their primary goal. Those who did not had greater functional limitations at the start of the study than those who did. Walking was the most common goal (17/78, 22%) and the most performed activity (135 times, 33%). Thirteen participants achieved walking and 12 of these were still walking outside at the 10-month assessment.

Three-quarters of people with stroke were therefore able to achieve their outdoor mobility goals after an occupational therapy intervention.

The Use of Transport by Stroke Patients

The objectives of this research were to survey the use of transport by stroke patients in the community and study its relationship to their activities of daily living and mood.

The records of 90 consecutive stroke patients receiving community occupational therapy in a rehabilitation trial were surveyed for entries of therapy related to transport. A further 50 stroke patients in the same study were surveyed about their use of transport one year after discharge from hospital.

In the survey of occupational therapy notes, a transport assessment had been recorded for all 90 patients. Of these, 22 patients had been given leaflets describing the range of transport options locally but had been unable to use these options.

In the survey of transport use, 42/50 (84%) patients surveyed at one year responded. Twenty-one (50%) had used transport on their own, six of whom scored <26/66 on the Extended Activities of Daily Living scale (indicating that they needed help in most activities of daily living). Twenty-one (50%) patients had not travelled alone, four of whom scored >48/66 on the Extended Activities of Daily Living scale (very able in activities of daily living). Only 1 (2%) patient had used specialist transport and 22 (52%) reported that they did not get out as much as they wished.

Despite receiving advice, these patients did not use specialist transport options, yet many still wanted to get out more. The reason for this is unclear but it is not due simply to physical disability.

New horizons: the management of hypertension in people with dementia

The optimal management of hypertension in people with dementia is uncertain. This review explores if people with dementia experience greater adverse effects from antihypertensive medications, if cognitive function is protected or worsened by controlling blood pressure (BP) and if there are subgroups of people with dementia for whom antihypertensive therapy is more likely to be harmful. Robust evidence is scant, trials of antihypertensive medications have generally excluded those with dementia. Observational data show changes in risk association over the life course, with high BP being a risk factor for cognitive decline in mid-life, while low BP is predictive in later life. It is therefore possible that excessive BP lowering in older people with dementia might harm cognition. From the existing literature, there is no direct evidence of benefit or harm from treating hypertension in people with dementia. So what practical steps can the clinician take? Assess capacity, establish patient preferences when making treatment decisions, use ambulatory monitoring to thoroughly assess BP, individualise and consider deprescribing where side effects (e.g. hypotension) outweigh the benefits. Future research might include pragmatic randomised trials of targeted deprescribing, which include patient-centred outcome measures to help support decision-making and studies to address mechanistic uncertainties.

Diagnostic test accuracy of informant-based tools to diagnose dementia in older hospital patients with delirium: a prospective cohort study

BACKGROUND

delirium and dementia co-exist commonly in hospital. Older people with delirium have high rates of undiagnosed dementia, but delirium affects the use of cognitive testing in dementia diagnosis. Novel methods to detect dementia in delirium are needed. The purpose of the study was to investigate the diagnostic test accuracy of informant tools to detect dementia in hospitalised older people with delirium.

METHODS

the presence of dementia on admission was assessed using the short form of the Informant Questionnaire of Cognitive Decline in the Elderly (IQCODE-SF) and Alzheimer's Disease 8 (AD8) in people over 70 years old with delirium. Reference standard diagnosis was made using Diagnostic and Statistical Manual of Mental Disorders fourth edition (DSM-IV) criteria at 3 months. The main outcome measures were the diagnostic test accuracy of the IQCODE-SF and the AD8 in diagnosing DSM-IV dementia.

RESULTS

dementia prevalence at 3 months was 61%. The area under the receiver operating characteristic curve (AUROC) was 0.93 (P < 0.0005) for admission IQCODE-SF and 0.91 (P < 0.0005) for admission AD8. An IQCODE-SF test result of >3.82 on admission had a sensitivity of 0.91 (0.79-0.97) and specificity of 0.93 (0.76-0.99) for detecting dementia. An AD8 of >6 had a sensitivity of 0.83 (0.69-0.92) and specificity of 0.90 (0.72-0.97) for detecting dementia.

CONCLUSION

the IQCODE-SF and AD8 are sensitive and specific tools to detect prior dementia in older people with delirium. The routine use of either tool in practice could have important clinical impact, by improving the recognition and hence management of those with dementia.