Enhancing medication management of older adults in Qatar: healthcare professionals' perspectives on challenges, barriers and enabling solutions.

Background: Polypharmacy and potentially inappropriate medications are significant challenges in older adults' medication management. The Consolidated Framework for Implementation Research (CFIR) is a comprehensive approach used to explore barriers and enablers to the healthcare system in guiding the effective implementation of evidence-based practices. Objectives: This study examines the barriers and enablers to promote safe medication management among older adults in Qatar from healthcare professionals' perspectives. This includes identifying critical factors within the healthcare system influencing medication management and suggesting practical solutions to improve it. Design: The study employs a qualitative design. Focus Groups (FGs) were conducted with healthcare professionals from the geriatric, mental health and medicine departments of Hamad Medical Corporation (HMC), the leading governmental sector in Qatar serving the older adult population. Methods: Utilising the CFIR, this study analysed feedback from healthcare professionals through FGs at HMC. A combined inductive and deductive thematic analysis was applied to transcripts from five FGs, focusing on identifying barriers and enablers to safe medication management among older adults. Two researchers transcribed the audio-recorded FG discussions verbatim, and two researchers analysed the data using a mixed inductive and deductive thematic analysis approach utilising CFIR constructs. Results: We engaged 53 healthcare professionals (31 physicians, 10 nurses and 12 clinical pharmacists) in FGs. The analysis identified current barriers and enabler themes under different CFIR constructs, including inner settings, outer settings, individual characteristics and intervention characteristics. We identified 44 themes, with 25 classifieds as barriers and 19 as enablers. The findings revealed that barriers and enablers within the inner settings were primarily related to structural characteristics, resources, policies, communication and culture. On the other hand, barriers and enablers from the outer settings included patients and caregivers, care coordination, policies and laws, and resources. Conclusion: This study identified several barriers and enablers to promote medication management for older adults using the CFIR constructs from the perspective of healthcare professionals. The multifaceted findings emphasise involving stakeholders like clinical leaders, policymakers and decision-makers to address medication safety factors. A robust action plan, continuously monitored under Qatar's national strategy, is vital. Further research is needed to implement recommended interventions.

Medication management challenges and solutions for older adults in Qatar: insights from healthcare professionals As people age, they often need multiple medications to manage their health conditions. However, taking medications that are not needed can cause harm. To improve medication management in this vulnerable population, it is essential to understand the barriers and enablers that healthcare professionals (HCPs) face. Our study used focus groups to explore these factors from the perspectives of healthcare providers in Qatar's Hamad Medical Corporation (HMC). We used the Consolidated Framework for Implementation Research (CFIR) to collect and analyse the data. Healthcare Professionals emphasised that the significant barriers to safe medication management in older adults include: • The missing medication history in electronic health records in many cases. • There is a lack of clinical decision support systems that guide and save prescribers time. • There is limited access to services such as medication therapy management and telemedicine. These services could facilitate managing complex or urgent cases. • Sometimes, communication between healthcare providers, patients, and caregivers is inadequate. It could be due to limited clinic time, HCPs' experience, or patients' health literacy. • There are unclear guidelines and policies regarding prescribing, dispensing, and stopping medications for older adults. • There is insufficient education for sub-specialists, junior HCPs, patients, and caregivers about the challenges of managing older adults' medications. • Limited patient engagement in their medication management plans could be due to low health literacy, social support, or physical or cognitive disabilities. • In addition to overcoming the previous challenges, HCPs suggested implementing a national strategy to utilise, guide, and monitor all the efforts. In conclusion, through our study, HCPs highlight the need for tailored national interventions to optimise safe medication management in older adults. The findings can inform the need for developing long-term and comprehensive strategies to help healthcare systems manage older adults' medications, leading to better health outcomes for this vulnerable population.

The usage of anticholinergic medications in a low- and middle-income country: a longitudinal comparison of 2013-15 and 2020-22 datasets.

BACKGROUND: While the effects of anticholinergic drug use have been increasingly highlighted, trends in anticholinergic use remain poorly understood. AIM: To determine the changes in frequency and pattern of anticholinergic drug use within a low- and middle-income country. METHOD: Comparisons were made between population-based datasets collected from Malaysian residents aged 55 years and older in 2013-15 and 2020-22. Anticholinergic exposure was determined using the anticholinergic cognitive burden (ACB) tool. Drugs with ACB were categorised according to the Anatomical Therapeutic Chemical (ATC) classification. RESULTS: A total number of 5707 medications were recorded from the 1616 participants included in the 2013-15 dataset. A total number of 6175 medications were recorded from 2733 participants in 2020-22. Two hundred and ninety-three (18.1%) and 280 (10.2%) participants consumed ≥ 1 medication with ACB ≥ 1 in 2013-15 and 2020-22 respectively. The use of nervous system drugs with ACB had increased (27 (0.47%) versus 39 (0.63%). The use of ACB drugs in the cardiovascular (224 (3.9%) versus 215 (3.4%)) and alimentary tract and metabolism (30 (0.52%) versus 4 (0.06%)) classes had reduced over time. Participants in 2020-22 were significantly less likely than those in 2013-15 to have total ACB = 1 - 2 (odds ratio [95% confidence interval] = 0.473[0.385-0.581]) and ACB ≥ 3 (0.251[0.137 - 0.460]) compared to ACB = 0 after adjustment for potential confounders (p < 0.001). CONCLUSION: Although anticholinergic exposure has decreased over time, the use of medications with anticholinergic effects in the nervous system class has risen. This increase is attributable to antipsychotic use, which is of concern due to potential cardiovascular complications, and deserves further evaluation.

Anticholinergic burden and health-related quality of life among adult patients in a resource-limited setting: a cross-sectional study.

BACKGROUND: Anticholinergic medications are now widely acknowledged for their unfavorable risk-to-benefit profile owing to their adverse effects. Health-related quality of life (HRQoL) is commonly regarded as a crucial person-centered outcome. AIM: This study aimed to investigate the association between anticholinergic burden and HRQoL in hospitalized and ambulatory patients seen in Ethiopia. METHOD: This cross-sectional study utilized a questionnaire and medical records to collect data from a convenience sample of adult patients attending both inpatient wards and ambulatory clinic of University of Gondar Comprehensive Specialized Hospital between April and September 2022. Anticholinergic burden was measured by anticholinergic cognitive burdens scale (ACBS), while HRQoL was measured using EQ5D-index (Euroqol-5 dimensions-5-Levels index) and EQ5D-VAS (visual analogue scale). Linear regression was used to assess the influence of high anticholinergic burden (ACBS score ≥ 3) on EQ5D-index and EQ5D-VAS, with adjustments made for sociodemographic and clinical confounders. RESULTS: A total of 828 patients participated in this study (median (IQR) age was 45.0 (30, 60) and 55.9% were female). On multiple linear regression analysis, high anticholinergic burden was associated with a statistically significant decline in HRQoL, as evidenced by reductions in both EQ5D index (- 0.174 (- 0.250, - 0.098)) and EQ5D-VAS scores (- 9.4 (- 13.3, - 5.2)). CONCLUSION: A significant association between high anticholinergic burden and diminished HRQoL was found among a relatively younger cohort in a resource-limited setting, even after adjustment for important confounding variables. Clinicians should be cognizant of the cumulative impact of anticholinergic burden on HRQoL outcomes and strive to minimize anticholinergic burden.

An increasing proportion of the population is not covered by the current RDA for vitamin C - interrogation of EPIC-Norfolk and NHANES 2017/2018 cohorts.

With the rising prevalence of obesity globally, increasing proportions of the population may not be covered by current recommended daily allowances (RDAs) that are supposed to provide 97.5% of the population with a sufficient nutrient status but are typically based on a healthy young 70 kg male reference person. Using the EPIC-Norfolk (UK) and the NHANES (US) cohorts, we estimated the effect of body weight on the dose-concentration relationship to derive weight-based requirements to achieve an 'adequate' plasma concentration of vitamin C estimated to be 50 µmol/L. Inverse correlations between body weight and vitamin C were observed in both cohorts (p < 0.0001). Moreover, only about 2/3 of the cohorts achieved an adequate plasma vitamin C status by consuming the RDA or above, while only 1/3 to 1/2 of the cohorts achieved adequacy by an intake of the local RDA ± 10%. Using vitamin C as an example, the present data demonstrate that a considerable and expectedly increasing proportion of the world population is unable to achieve an adequate target plasma concentration with the current recommended daily intakes of vitamin C. This needs to be considered in future public health recommendations.

In this paper, we highlight the inverse association between body weight and vitamin C status. Our study strongly suggests that a large proportion of the population is not covered by the current recommended intakes of vitamin C.

Enhancing Medication Safety through Implementing the Qatar Tool for Reducing Inappropriate Medication (QTRIM) in Ambulatory Older Adults.

INTRODUCTION: To promote optimal healthcare delivery, safeguarding older adults from the risks associated with inappropriate medication use is paramount. OBJECTIVE: This study aims to evaluate the effectiveness of implementing the Qatar Tool for Reducing Inappropriate Medication (QTRIM) in ambulatory older adults to enhance medication safety. METHOD: The QTRIM was developed by an expert consensus panel using the Beers Criteria and contained a list of potentially inappropriate medications (PIMs) based on the local formulary. Using quality improvement methodology, it was piloted and implemented in two outpatient pharmacy settings serving geriatric medicine and dermatology clinics at Rumailah Hospital, Qatar. Key performance indicators (KPIs) using implementation documentation as a process measure and the percentage reduction in PIM prescriptions as an outcome measure were assessed before and after QTRIM implementation. This study was conducted between July 2022 and September 2023. RESULTS: In the outpatient department (OPD) geriatric pharmacy, the prescription rate of PIMs was reduced from an average of 1.2 ± 0.7 PIMs per 1000 orders in 2022 to an average of 0.8 ± 0.2 PIMs per 1000 orders in 2023. In the OPD geriatric pharmacy, the results showed a 66.6% reduction in tricyclic antidepressants (TCAs) (from 30 to 10), a reduction in first-generation antihistamines by 51.7% (29 to 14), and muscle relaxants by 33.3% (36 to 24). While in dermatology, the older adult prescription rate of PIMs was reduced from an average of 8 ± 3 PIMs per 1000 orders in 2022 to a rate of 5 ± 3 PIMs per 1000 orders in 2023; the most PIM reductions were (49.4%) in antihistamines (from 89 to 45), while muscle relaxants and TCAs showed a minimal reduction. CONCLUSIONS: Implementing QTRIM with pharmacy documentation monitoring markedly reduced the PIMs dispensed from two specialized outpatient pharmacies serving older adults. It may be a promising effective strategy to enhance medication safety in outpatient pharmacy settings.

Anticholinergic burden among in-patients: a cross-sectional study on prevalence, determinants, and impact on mortality in Ethiopia.

Background: Numerous studies report that anticholinergic burden (ACB) has been linked with several health consequences, including increased hospital admissions, prolonged hospitalization, and physical and cognitive impairment. However, low- and middle-income settings, as well as younger individuals, are underrepresented. Objectives: To assess the prevalence and determinants of ACB, and to assess the impact of ACB on in-hospital mortality among adult in-patients at University of Gondar Comprehensive Specialized Hospital (UOGCSH). Design: A cross-sectional study was conducted from June to August 2022 at UOGCSH among adult in-patients. Methods: A pre-tested questionnaire was utilized to collect data from patients and their corresponding medical charts. A consecutive sampling technique was used to select the participants. Descriptive statistics were used to summarize socio-demographic and clinical characteristics. Chi-squared, Fisher's exact, and Wilcoxon rank sum tests, as appropriate, were used to determine associations between independent variables and ACB. Kaplan-Meier survival curve and Cox proportional hazards regression test were used to assess the impact of ACB on in-hospital mortality. Results: A total of 420 adult in-patients, median (interquartile range) age of 38 (26, 55) years, participated in this study. Over half (58.3%) were exposed to anticholinergic medicines, with a high ACB (⩾3) seen in 11.2% of participants. High ACB was associated with higher median number of medicines per patient (p = 0.003) higher median hospital length of stay (p = 0.033), and having mental and behavioral disorders (p < 0.001). No significant association was found between ACB and in-hospital mortality (log-rank test p = 0.26, Cox regression adjusted hazard ratio: 1.47, 95% CI: 0.335-6.453, p = 0.61). Conclusion: Among adult in-patients, a significant majority (58.3%) were subjected to medications possessing anticholinergic properties, with a noteworthy 11.2% of the study subjects exhibiting a high ACB. Participants with higher median length of hospital stay were more likely to have high ACB even in this relatively younger adult patient population.

Background: Anticholinergics refers to substances that block the action of the neurotransmitter acetylcholine in the body. Previous studies have shown that medicines exhibiting anticholinergic effects could lead to increased hospital admissions, longer hospital stays, and both physical and cognitive impairments. Objective: In this study, we aimed to assess how medicines exhibiting anticholinergic effects might affect patients in Ethiopian in-patient settings. Methods: We conducted a cross-sectional study from June to August 2022, collecting data from adult in-patients through a questionnaire and medical charts. We used a widely recognized tool called Anticholinergic Cognitive Burden Score to measure anticholinergic burden. We used statistical analyses to identify associations between the use of anticholinergic medicines and various factors, including the number of medicines per patient and the length of hospital stay. Additionally, we explored the impact of anticholinergic burden on in-hospital mortality. Results: Out of the 420 participants, 245 were exposed to medicines with anticholinergic properties. High anticholinergic burden was observed in 47 patients. Patients with mental and behavioral disorders were more likely to have high anticholinergic burden, while those with diseases of the digestive system were less likely. Moreover, a high anticholinergic burden was linked to a greater median number of medicines per patient and an extended median hospital length of stay. However, the study found no significant difference in in-hospital mortality between patients with high and low anticholinergic burden. Conclusion: The study highlights that a significant proportion of the participants were exposed to medicines with anticholinergic properties, and a notable percentage experienced a high anticholinergic burden. This burden was particularly associated with mental and behavioral disorders, the use of higher number of medicines, and longer hospital stay. Importantly, the research did not find a clear link between anticholinergic burden and in-hospital mortality after accounting for other factors.

Understanding the impact of medicines with anticholinergic properties on patients at University of Gondar Hospital.

Impact of age on the prevalence of poor-quality dietary variety, associated lifestyle factors, and body composition profile (low body muscle mass and high body fat mass) in older people residing in Colombo district, Sri Lanka.

Aims: To assess the impact of age on the prevalence of poor-quality dietary variety, associated lifestyle factors, and body composition profile (low body muscle mass and high-fat mass) in older Sri Lankans. Methods: In this population-based cross-sectional study, older people of 60 years or above were selected using a multistage cluster sampling technique probability proportionate to the size. They were classified into 3 groups; 60-64, 65-69 and > 70-years. The poor-quality dietary variety was defined based on food variety, dietary diversity and dietary serving scores assessed using 24-h dietary recall. Body composition was measured using bio-electrical impedance. The impact of age on determinants of poor-quality dietary variety and being at risk of low muscle mass and high-fat mass were assessed by using multivariable logistic regression models. Results: Eight hundred older participants with a mean (SD) 68.1(5.8) years were included. There were 28.4%(n = 227), 36.2%(n = 290) and 35.4%(n = 283) in the 60-64, 65-69 and ≥ 70-year age groups, respectively. The prevalence of poor-quality dietary variety was similar across age groups. The urban living environment, and getting nutritional advice from the GP/hospital were found to have a significant negative association only in the 60-64 age group. A poor-quality dietary variety was significantly associated with no education or up to the primary level in the 65-69 age group and having diabetes or hypertension in the ≥70-year group. Odds of low muscle mass and high-fat mass were 2.43(1.46-4.03) and 2.17(1.30-3.63) respectively among the≥70-year age group compared to the 60-64-year group, after controlling for confounders. Conclusions: The prevalence of poor-quality dietary variety was similarly high in all age groups. Increasing age was associated with higher odds of low body muscle and high body fat mass despite similar dietary variety, indicating the need for special dietary attention.

Impact of remoteness and rurality on the treatment and survival of patients with glioblastoma in the north of Scotland.

Background: The geographical catchment area served by the Neurosurgical Unit in Aberdeen, Scotland is the largest in the United Kingdom. We examined whether a distance-decay effect on survival exists for patients diagnosed with glioblastoma, who have to travel substantial distances for neurosurgical and oncological treatment in the north of Scotland. Methods: Electronic medical records of adult patients with glioblastoma, referred for treatment between 2007 and 2018, who underwent surgical resection were reviewed. Travel time by car (as a measure of distance travelled) was calculated from the patients' home to their general practice (GP) and to their main neuro-oncological centre. Results: There were 122 patients; 71 (58.2%) were male and the mean age was 57.8 years. The urban-rural split was 61.5% and 38.5%, respectively. Median driving time to the neuro-oncological centre was 36 min and to the GP this was 6 min. Most patients underwent either sub-total (49.6%) or gross total (46.3%) surgical resection. Post-operative treatments included: radiotherapy only (15.6%), chemotherapy only (6.6%), and chemotherapy with radiotherapy (63.1%). Temozolomide was used in 70.5% of patients. Seventeen patients did not receive any post-operative chemo-radiotherapy. The median survival time was 345 days. There was no statistically significant association between distance travelled and survival time in days. MGMT methylation status, extent of resection, Charlson co-morbidity index and treatment received significantly affected survival. Conclusions: There was no evidence of disadvantage on survival time for patients living further from their neuro-oncological centre compared to those who live nearer.

Diabetes mellitus increases risk of adverse drug reactions and death in hospitalised older people: the SENATOR trial.

PURPOSE: Adverse drug reactions (ADRs) are a major cause of morbidity and mortality, especially in older people. Older people with diabetes mellitus may be at especially high risk of ADRs but this risk has not been well studied. This study aimed to compare severity and type of ADRs in hospitalised, multimorbid older people with and without diabetes and secondly to assess the impact of ADRs on mortality, rehospitalisation and length of stay. METHODS: Participants in the SENATOR (Software Engine for the Assessment and optimization of drug and non-drug Therapy in Older peRsons) trial were assessed for 12 common and 'other' prevalent and incident adverse drug reactions using a blinded end-point adjudication process. Descriptive analyses, logistic regression and mediation analyses were undertaken. RESULTS: Of 1537 people in the SENATOR trial, 540 (35.1%) had diabetes mellitus (mean age 77.4 ± 7.3 years, 58.5% male). In the total population, 773 prevalent and 828 incident ADRs were reported. Both prevalent and incident symptomatic hypoglycaemia and incident acute kidney injury (AKI) were significantly more common in people with diabetes (p < 0.05). Patients with diabetes had higher all-cause mortality at 12 weeks than those without (9.1% vs 6.3%, p = 0.04). Mediation analysis revealed that mortality was significantly higher (OR = 1.43, Sobel test p = 0.048) in people with diabetes and ADRs causing AKI. CONCLUSIONS: Older multimorbid people with diabetes presenting to hospital with acute illness have significantly more ADRs than those without, and a significantly higher mortality that is mediated by medication-associated AKI and poorer renal function.

Glycated Haemoglobin (HbA1c) and Future Physical and Mental Functional Health in the European Prospective Investigation into Cancer (EPIC)-Norfolk Population-Based Study.

Little is understood about the relationship between glycated haemoglobin and future functional health in the general population. In this work, we aimed to assess if glycaemic control is associated with future physical and mental functional health at 18-month follow-up in a UK general population, in those with and without diabetes. This work was a cross-sectional study. Between 1995 and 1997, participants of the European Prospective Investigation into Cancer, Norfolk, attended a health check including blood testing for haemoglobin A1c (HbA1c) and completed a health and lifestyle questionnaire. Eighteen months later, self-reported physical and mental functional health were assessed using short form-36 (SF-36). Outcomes of interest included physical and mental component summary (PCS and MCS, respectively) scores of the SF-36. A total of 7343 participants (56% women, mean (SD) 58.1 ± 9.5 years) were eligible to be included, of whom 167 had prevalent diabetes. In our linear regression analysis, a higher HbA1c (mmol/mol) was found to be associated with a poorer PCS score (coefficient -0.15 (p < 0.0001)) at follow-up. After adjustment for comorbid conditions, including obesity, this association was no longer statistically significant. A higher HbA1c (mmol/mol) was associated with a better MCS score at follow-up; this finding was significant when adjusted for comorbid conditions (coefficient 0.029 (p < 0.05)). Our findings suggest that the association between a higher HbA1c and poorer physical functional health is explained by a higher BMI and comorbidity status in a general population. While higher HbA1c was found to be associated with higher mental functional health at follow-up, the magnitude of this association was small. Healthy responder bias and unmeasured confounding variables may have influenced this result; thus, it should be interpreted with caution.

National audit of pathways in epileptic seizure referrals (NAPIER): A national, multicentre audit of first seizure clinics throughout the UK and Ireland.

BACKGROUND: Current guidelines set clinical standards for the management of suspected first seizures and epilepsy. We aimed to assess if these standards are being met across first seizure clinics nationally, to describe variations in care and identify opportunities for service delivery improvement. METHODS: Multicentre audit assessing the care of adults (≥16 years) referred to first seizure clinics from 31st December 2019 going backwards (30 consecutive patients per centre). Patients with pre-existing diagnosis of epilepsy were excluded. Anonymised referral, clinic, and follow-up data are reported with descriptive statistics. RESULTS: Data provided for 727 patients from 25 hospitals in the UK and Ireland (median age 41 years [IQR 26-59], 52% males). Median time to review was 48 days (IQR 26-86), with 13.8% (IQR 3.3%-24.0%) of patients assessed within 2 weeks. Seizure recurrence was seen in 12.7% (IQR 6.6%-17.4%) of patients awaiting first appointment. Documentation for witness accounts and driving advice was evident in 85.0% (IQR 74.0%-100%) and 79.7% (IQR 71.2%-96.4%) of first seizure/epilepsy patients, respectively. At first appointment, discussion of sudden unexpected death in epilepsy was documented in 30.1% (IQR 0%-42.5%) of patients diagnosed with epilepsy. In epilepsy patients, median time to MRI neuroimaging was 37 days [IQR 22-56] and EEG was 30 days [IQR 19-47]. 30.4% ([IQR 0%-59.5%]) of epilepsy patients were referred to epilepsy nurse specialists. CONCLUSIONS: There is variability nationally in the documented care of patients referred to first seizure clinics. Many patients are facing delays to assessment with epilepsy specialists with likely subsequent impact on further management.

In-hospital outcomes of acute ischaemic stroke patients with atrial septal defect. A national inpatient sample study.

BACKGROUND AND AIMS: Atrial septal defects (ASD) are a well-recognised risk factor for acute ischaemic stroke (AIS). We aimed to delineate the relationship between ASD and in-hospital AIS outcomes (mortality, severe stroke (National Institutes of Health Stroke Scale (NIHSS) > 15), prolonged hospitalisation > 4 days and routine home discharge) in contemporary practice using data from the United States National Inpatient Sample. METHODS: NIS admissions with a primary diagnosis of AIS between 2016-2018 were extracted. The NIHSS variable had 75% missing data, which were imputed using multiple imputations by chained equations. The relationship between ASD and the main outcomes was modelled using multivariable logistic regressions, adjusting for age, sex, comorbidities, stroke severity and revascularisation therapies. RESULTS: 245,859 records representative of 1,229,295 AIS admissions were included, 35,840 (2.91%) of whom had ASD. ASD patients were younger (median age 63 years versus 72 years) and less likely to have traditional cardiovascular risk factors than their counterparts without ASD. ASD was independently associated with 58% lower odds of in-hospital mortality (hazard ratio (95% confidence interval) = 0.42 (0.33-0.54)), 18% lower odds of severe stroke (0.82 (0.71-0.94)), 20% higher odds of routine home discharge (1.20 (1.14-1.28)) and 28% higher odds of prolonged hospitalisation (1.28 (1.21-1.35)). CONCLUSIONS: ASD was associated with better in-hospital outcomes, which were likely driven by younger age, lower prevalence of traditional cardiovascular risk factors, and lower stroke severity. Further research is warranted to clarify the ASD anatomical characteristics which are most strongly associated with these associations.

Calcaneal broadband ultrasound attenuation predicts physical capability: EPIC-Norfolk prospective population-based study.

BACKGROUND: Calcaneal ultrasound (broadband ultrasound attenuation - BUA), a marker of bone strength, may predict future physical capability and thus provide a strategy to identify individuals at risk of age-related deterioration of health. This study aims to determine if BUA can predict future physical capability among middle-aged and older adults. METHODS: Summary performance scores (SPS), an objective quantification of physical capability, were devised using participants' measures of standing balance, gait speed and timed chair rises. Associations between BUA and SPS, measured at least six years apart, were investigated using univariable and multivariate sex-specific linear and logistic regression, adjusting for confounders. RESULTS: 5893 participants were included. In men and women, for every five points lower BUA, there was a 0.2-point decrease in SPS. In women, BUA less than one standard deviation below the mean was associated with low physical capability (defined as SPS 3-6); fully adjusted odds ratio (OR) (95 % confidence interval (CI)) 1.35 (1.01-1.84). No association existed among men; OR (95 % CI) 0.84 (0.59-1.19). Significant risk factors for low physical capability in men with baseline low BUA were: older age [OR 5.77]; high BMI [OR 2.85]; lower social class [OR 1.59]; low physical activity [OR 1.64]. Risk factors among women were: older age [OR 5.54]; high BMI [OR 2.08]; lower education [OR 1.42], low physical activity [OR 1.27]; steroid use [OR 2.05]; and stroke [OR 2.74]. CONCLUSION: BUA may predict future physical capability in older adults. With further validation, BUA could stratify individuals at risk of deterioration in physical health.

Education Intervention Has the Potential to Improve Short-Term Dietary Pattern among Older Adults with Undernutrition.

Low-cost educational interventions to improve dietary pattern is a pragmatic solution to prevent undernutrition in low- and middle-income countries. A prospective nutritional education intervention was conducted among older adults aged 60 years or above with undernutrition with 60 people in each intervention and control group. The objective was to develop and evaluate the efficacy of a community-based nutrition education intervention to improve the dietary pattern of older adults with undernutrition in Sri Lanka. The intervention consisted of two modules to improve the diversity, the variety of diet, and the serving sizes of food consumed. The primary outcome was the improvement of the Dietary Diversity Score (DDS) and the secondary outcomes were the Food Variety Score and Dietary Serving Score, which was assessed using the 24 h dietary recall. The mean difference in scores between the two groups was compared using the independent sample t-test at baseline, two weeks and three months post-intervention. Baseline characteristics were comparable. After two weeks, only the difference in DDS between the two groups was statistically significant (p = 0.002). However, this was not sustained at three months (p = 0.08). This study concludes that nutrition education interventions have the potential for short-term improvement in dietary patterns in older adults in a Sri Lanka setting.

Ultrafiltration versus Diuretics on Prognostic Cardiac and Renal Biomarkers in Acute Decompensated Heart Failure: A Systematic Review and Meta-Analysis.

Existing systematic reviews have insufficiently delineated the differing cardiac and renal profile of ultrafiltration compared to diuretics as a method of decongestion in acute decompensated heart failure. This meta-analysis will investigate the impact of ultrafiltration compared to diuretics on prognostic cardiac and renal biomarkers. We searched PubMed Central, Ovid MEDLINE®, Ovid Embase, all EBM reviews, and Web of Science Core Collection for randomised controlled trials published before 21 July 2022. Our main outcome measures were cardiac (brain natriuretic peptide and N-terminal pro-brain natriuretic peptide) and renal biomarkers (serum creatinine, serum sodium, and blood urea nitrogen). A total of 10 randomised trials were included in our analysis after screening. An inverse-variance random effects meta-analysis of the pooled results demonstrated no significant difference between ultrafiltration and diuretics for brain natriuretic peptide, N-terminal pro-brain natriuretic peptide, creatinine, sodium and long-term blood urea nitrogen. However, ultrafiltration produced statistically greater increases in blood urea nitrogen in the short-term (mean difference, 3.88; 95% confidence interval 0.59-7.17 mg/dL). Overall, ultrafiltration produces a similar impact on prognostic cardiac and renal biomarkers when compared to diuretic therapy. We highlight ultrafiltration's significant impact on short-term BUN and recommend further research to investigate more optimal protocols of ultrafiltration administration.

An unusual case of neurocardiogenic syncope: A case report and systematic review.

We present a case of syncopal episode in emergency department (ED) and subsequent admission to the geriatric assessment unit. The patient presented with self-limiting central abdominal pain. Given a history of previous aortic aneurysm repair, a contrast CT angiogram was performed. With no evidence of leaking aneurysm, the patient was discharged from the ED. The syncopal episode happened while waiting for a taxi. A review of the earlier CT scan showed the presence of air in the venous circulatory system. In hindsight, it was thought the syncopal episode occurred due to air embolism introduced during or shortly after venous cannulation. We discuss the aetiology of venous air embolism and highlight the lack of evidence regarding tolerable amounts of air in the circulatory system. Physiological changes associated with age may suggest that elderly patients are uniquely maladapted to overcome sudden insults to their cardiovascular status.

SHARP risk score: A predictor of poor outcomes in adults admitted for emergency general surgery: A prospective cohort study.

PURPOSE: Post-operative complications following emergency abdominal surgery are associated with significant morbidity and mortality. Despite the knowledge of prognostic factors associated with poor surgical outcomes; few have described risks of poor outcomes based on admission information in acute surgical setting. We aimed to derive a simple, point-of-care risk scale that predicts adults with increased risk of poor outcomes. METHODS: We used data from an international multi-centre prospective cohort study. The effect of characteristics; age, hypoalbuminaemia, anaemia, renal insufficiency and polypharmacy on 90-day mortality was examined using fully adjusted multivariable models. For our secondary outcome we aimed to test whether these characteristics could be combined to predict poor outcomes in adults undergoing emergency general surgery. Subsequently, the impact of incremental increase in derived SHARP score on outcomes was assessed. RESULTS: The cohort consisted of 419 adult patients between the ages of 16-94 years (median 52; IQR(39) consecutively admitted to five emergency general surgical units across the United Kingdom and one in Ghent, Belgium. In fully adjusted models the aforementioned characteristics; were associated with 90-day mortality. SHARP score was associated with higher odds of mortality in adults who underwent emergency general surgery, with a SHARP score of five also being associated with an increased length of hospital stay. CONCLUSIONS: SHARP risk score is a simple prognostic tool, using point-of-care information to predict poor outcomes in patients undergoing emergency general surgery. This information may be used to improve management plans and aid clinicians in delivering more person-centred care. Further validation studies are required to prove its utility.

Does Estimated Glomerular Filtration Rate Predict In-Hospital Mortality in Acutely Unwell Hospitalized Oldest Old?

Globally the population of older adults is the fastest growing age group. Estimated glomerular filtration rate (eGFR) is an estimation of true kidney function with lower eGFR associated with higher mortality. However, few studies explore eGFR's prognostic value in the nonagenarian. We investigated the association between eGFR on admission and mortality among the nonagenarians hospitalised with acute illness. A retrospective analysis of a prospective cohort study included patients aged ≥ 90 admitted into three acute medical assessment units or acute geriatric wards in England and Scotland between November 2008 and January 2009. Association between eGFR and all-cause mortality was evaluated using the Cox proportional hazard models controlling for potential confounders including frailty. 392 patients with mean (SD) 93.0 ± 2.6 years (68.45% women) were included. The median (IQR) eGFR was 26.61 (18.41-40.41) mL/min/1.732. 63 died in in hospital. Low eGFR was not associated with mortality (Hazard ratio (HR) 1.00 (95% CI 0.98-1.02) overall or in sub-group analysis by frailty (HR 0.96 (0.92-1.01)) or by eGFR of ≤30 (HR 1.01 (0.95-1.06). We found no evidence of prognostic value of eGFR in predicting in-hospital mortality in the acutely unwell hospitalised nonagenarians.