Frailty knowledge, training and barriers to frailty management: A national cross-sectional survey of health professionals in Australia.

OBJECTIVE(S): To understand Australian health professionals' perceptions of their knowledge and previous training about frailty, as well as barriers to frailty assessment and management in their practice. METHODS: A cross-sectional online survey was developed and distributed to health professionals (medical, nursing and allied health) engaged in clinical practice in Australia through convenience and snowball sampling techniques from March to May 2022. The survey consisted of five sections: frailty training and knowledge; confidence in recognising and managing adults with frailty; the importance and relevance of frailty; barriers to assessing and managing frailty in practice; and interest in further frailty training. Responses were analysed using descriptive statistics. RESULTS: The survey was taken by 736 health professionals. Less than half of respondents (44%, 321/733) reported receiving any training on frailty, with 14% (105/733) receiving training specifically focussed on frailty. Most respondents (78%, 556/712) reported 'good' or 'fair' understanding of frailty. The majority (64%, 448/694) reported being 'fairly' or 'somewhat' confident with identifying frailty. Almost all respondents (>90%) recognised frailty as having an important impact on outcomes and believed that there are beneficial interventions for frailty. Commonly reported barriers to frailty assessment in practice included 'lack of defined protocol for managing frailty' and 'lack of consensus about which frailty assessment tool to use'. Most respondents (88%, 521/595) were interested in receiving further education on frailty, with a high preference for online training. CONCLUSIONS: The findings suggest frailty is important to health professionals in Australia, and there is a need for and interest in further frailty education.

Navigating the machine learning pipeline: a scoping review of inpatient delirium prediction models.

OBJECTIVES: Early identification of inpatients at risk of developing delirium and implementing preventive measures could avoid up to 40% of delirium cases. Machine learning (ML)-based prediction models may enable risk stratification and targeted intervention, but establishing their current evolutionary status requires a scoping review of recent literature. METHODS: We searched ten databases up to June 2022 for studies of ML-based delirium prediction models. Eligible criteria comprised: use of at least one ML prediction method in an adult hospital inpatient population; published in English; reporting at least one performance measure (area under receiver-operator curve (AUROC), sensitivity, specificity, positive or negative predictive value). Included models were categorised by their stage of maturation and assessed for performance, utility and user acceptance in clinical practice. RESULTS: Among 921 screened studies, 39 met eligibility criteria. In-silico performance was consistently high (median AUROC: 0.85); however, only six articles (15.4%) reported external validation, revealing degraded performance (median AUROC: 0.75). Three studies (7.7%) of models deployed within clinical workflows reported high accuracy (median AUROC: 0.92) and high user acceptance. DISCUSSION: ML models have potential to identify inpatients at risk of developing delirium before symptom onset. However, few models were externally validated and even fewer underwent prospective evaluation in clinical settings. CONCLUSION: This review confirms a rapidly growing body of research into using ML for predicting delirium risk in hospital settings. Our findings offer insights for both developers and clinicians into strengths and limitations of current ML delirium prediction applications aiming to support but not usurp clinician decision-making.

Sex-specific interventions to prevent and manage frailty.

There is growing interest in interventions that delay, slow, and even reverse frailty. In this narrative review, we explore the evidence on exercise, nutrition, medication optimisation and social support interventions for frailty and consider how these relate to underlying frailty pathophysiology. We also consider pathophysiological mechanisms underpinning sex differences in frailty before evaluating the limited evidence for sex-specific frailty interventions that is currently available. Through this review of the literature, we generate a list of potential sex-specific interventions for frailty. While individual-level recommendations are certainly important, future work should turn the focus towards population-level interventions that take into account sex differences in frailty, including changes to healthcare and socioeconomic systems, as well as changes to the built environment to promote healthy behaviours.

Scoping Review of Studies Evaluating Frailty and Its Association with Medication Harm.

INTRODUCTION: Frailty is associated with an increased risk of death and morbid events. Frail individuals are known to have multiple comorbidities which are often associated with polypharmacy. Whilst a relationship between polypharmacy and frailty has been demonstrated, it is not clear if there is an independent relationship between frailty and medication harm. AIMS: This scoping review aimed to identify and critically appraise studies evaluating medication harm in patients with frailty. METHODS: PubMed, EMBASE, CINAHL and Cochrane databases were searched from inception until 1 February 2021 using key search terms that are synonymous with frailty (such as frail and frail elderly) and medication harm (such as adverse drug events and adverse drug reactions). To be included, studies must have identified medication harm as a primary or secondary outcome measure, and used a frailty assessment tool to determine frailty, or clearly defined how frailty was assessed. Data were narratively synthesised and presented in tables. The checklist from the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies from the National Heart, Lung, and Blood Institute was used to assess the quality and risk of bias of studies that met the inclusion criteria. RESULTS: Of 2685 retrieved abstracts, 24 underwent full-text review and nine studies met the inclusion criteria. Three studies were retrospective cohort studies, and six were prospective observational studies. Six studies comprised two distinct groups of frail and non-frail individuals, and the remaining three studies evaluated medication harm in an entirely frail population. Seven studies used validated frailty tools such as the Clinical Frailty Scale, Fried Frailty Index, and Fried Frailty Phenotype. Two studies measured frailty using self-defined criteria. Overall, frail individuals were at risk of medication harm with rates ranging between 18.7 and 77% across the nine studies. However, whether frailty is an independent predictor of medication harm remains uncertain, as this was only evaluated in one study. The risk of bias assessment identified limitations in methods and reporting with all nine studies. CONCLUSION: This scoping review identified nine studies evaluating medication harm in frail patients. However, all were limited by the methodological quality and inadequate reporting of study factors. There are few high-quality studies that described a relationship between medication harm and frailty. More robust studies are required that examine the independent relationship between frailty and medication harm, after adjusting for all possible confounders and in particular polypharmacy.

Cervical Cancer Screening Among Immigrant Women Residing in Australia: A Systematic Review.

Since the introduction of systematic population-based cervical cancer screening in Australia in 1991, age-standardized incidence of cervical cancer has halved. Given recent advances in human papillomavirus (HPV) vaccination and screening, cervical cancer may be eliminated nationally within 20 years. However, immigrant women are not equitably reached by screening efforts. This study systematically reviewed evidence on cervical cancer screening practices among immigrant women in Australia. A systematic search of MEDLINE, Embase, PubMed, CINAHL, and PsycINFO and gray literature for English language studies published till March 1, 2019, was conducted. Observational and qualitative studies evaluating cervical cancer screening awareness and participation of immigrant women were screened. Of 125 potentially relevant studies, 25 were eligible: 16 quantitative (four cohort, 12 cross-sectional), six qualitative, and three mixed-methods studies. Quantitative studies indicated 1% to 16% lower screening rates among migrant women compared with Australian-born women, with participation of South Asian women being significantly lower. Qualitative studies illustrated factors affecting women's willingness to participate in screening, including insufficient knowledge, low-risk perception, and unavailability of a female health professionals being key barriers. Future studies should focus on South Asian women, due to recent increase in their immigration.

Medication use and cognitive impairment among residents of aged care facilities.

BACKGROUND: Potentially inappropriate polypharmacy is common in residential aged care facilities (RACF). This is of particular concern among people with cognitive impairment who, compared with cognitively intact residents, are potentially more sensitive to the adverse effects of medications. AIM: To compare the patterns of medication prescribing of RACF residents based on cognitive status. METHODS: De-identified data collected during telehealth-mediated geriatric consultations with 720 permanent RACF residents were analysed. Residents were categorised into cognitively intact, mild to moderate impairment and severe impairment groups using the interRAI Cognitive Performance Scale. The number of all regular and when-required medications used in the past 3 days, the level of exposure to anti-cholinergic/sedative medications and potentially inappropriate medications and the use of preventive and symptom control medications were compared across the groups. RESULTS: The median number of medications was 10 (interquartile range (IQR) 8-14). Cognitively intact residents were receiving significantly more medications (median (IQR) 13 (10-16)) than those with mild to moderate (10 (7-13)) or severe (9 (7-12)) cognitive impairment (P < 0.001). Overall, 82% of residents received at least one anti-cholinergic/sedative medication and 26.9% were exposed to one or more potentially inappropriate medications, although the proportions of those receiving such medications were not significantly different across the groups. Of 7658 medications residents were taking daily, 21.3% and 11.7% were classified as symptom control and preventive medications respectively with no significant difference among the groups in their use. CONCLUSION: Our findings highlight the need for optimising prescribing in RACF residents, with particular attention to medications with anti-cholinergic effects.

Undertaking medication review by telehealth.

BACKGROUND: Medication review can be delivered using telehealth during the COVID-19 pandemic to ensure ongoing provision of care to vulnerable patient populations and to minimise risk of infection for both patients and health professionals. OBJECTIVE: The aim of this article is to discuss the evidence related to telehealth medication reviews and provide practical considerations for conducting successful medication reviews by telehealth. DISCUSSION: Leading up to the COVID-19 pandemic, telehealth technologies had been increasingly used to deliver medication review services, mainly to patients in rural and remote areas, and were accepted by patients. Available evidence suggests telehealth medication reviews may positively affect clinical and cost outcomes, but there are ongoing challenges. When delivering these services, appropriate preparation - using support people, maintaining patients' privacy, selecting the most suitable technology on the basis of individual circumstances and ensuring good communication between healthcare professionals involved in medication review cycle of care - can help produce best results for patients.

The Changes in Medication Prescribing Among the Older People with Cognitive Impairment in the Acute Care Setting.

PURPOSE: Most older people with cognitive impairment usually have multiple comorbidities. In the last decade, the guidelines for the management of chronic diseases have been changed, leading to changes in the patterns of medication prescribing and in the prevalence of drug-related problems (DRPs). The main objectives were to explore the changes in medication use and in the prevalence of polypharmacy (PP), the use of potentially inappropriate medications (PIMs) and drug-drug interactions (DDIs) among older hospitalized adults with cognitive impairment in a 5-year period. PATIENTS AND METHODS: Older hospitalized patients with cognitive impairment diagnosed by cognitive performance scale (CPS) score of 2 or more at tertiary hospital in Brisbane, Australia in 2009 and 2015 to 2016 were enrolled. Prescribed medication use, and exposures to PP, PIM and/or DDI were evaluated at two time points. The associated factors with patients exposed to >1 criteria of PP, PIM or DDI were analyzed by using logistic regression analyses. RESULTS: The median number of prescribed medications was not significantly different between the two periods. The number of medications use as dermatological agents and analgesics substantially increased over 5 years. In contrast, there was a decrease in prescription of drugs for acid-related disorders, drugs used in diabetes, and mineral supplements. Most of the participants were exposed to at least one of PP, PIM or DDI. In multivariate regression analysis, the presence of diabetes diagnosis was a risk factor associated with increased exposure to >1 criteria of PP, PIM or DDI. CONCLUSION: The patterns of many prescribed medications use have altered in a 5-year period. The present study confirms that the majority of older adults with cognitive impairment admitted in an acute care setting are prone to PP, PIM and DDI. Comprehensive medication reviews should be undertaken in clinical care of older patients with cognitive impairment.

A scoping review of the use and impact of telehealth medication reviews.

BACKGROUND: Telehealth has been proposed as a mechanism to overcome the practical difficulties associated with conducting timely and efficient medication reviews particularly in rural and remote settings. OBJECTIVE: The aim was to examine the literature on the use and impact of telehealth-facilitated medication reviews. METHODS: A scoping review of the literature was conducted. Articles that reported medication reviews performed by telehealth were identified by searching the Pubmed, Embase, Cochrane Library and CINAHL databases to January 2019 and screened using predefined inclusion criteria. Data were extracted from included articles and synthesised narratively. Findings are reported using the PRISMA-ScR guidelines. RESULTS: Twenty-nine studies, including 15 descriptive and 14 quasi-experimental studies, met the inclusion criteria. Twenty studies were reports of the implementation and/or evaluation of a service and others were proof of concept, feasibility or pilot studies. Telehealth medication reviews, conducted as standalone interventions or as a part of team-based care, included medication order reviews, medication management, antimicrobial stewardship programs and geriatric services and were delivered to patients in outpatient (n = 15) or hospital (n = 12) settings, with one study conducted in residential care and one study across settings. Outcomes reported included process evaluation (n = 23), medication use (n = 8), costs (n = 6), clinical outcomes (n = 5), and healthcare use (n = 1). Positive impact was observed on clinical outcomes (e.g. reduction in haemoglobin A1c), medication use (e.g. reduction in antimicrobial medications) and costs (e.g. savings due to travel avoided). Good overall satisfaction with the interventions was seen in all studies that reported patient satisfaction. CONCLUSIONS: The current evidence suggests that telehealth medication review may be a feasible model for delivering these services and potentially can save costs and improve care. However, the level of evidence may not be sufficient to reliably inform practice and policy on telehealth-facilitated medication-reviews.

Using telehealth to enable collaboration of pharmacists and geriatricians in residential medication management reviews.

Background Practical issues impede optimum collaboration between pharmacists and other clinical specialists in the current Australian residential medication review services which potentially affect efficiency, timeliness and quality of outcomes. Objective This mixed methods study aimed to explore the potential value of an existing telehealth platform to enable collaboration of pharmacists and geriatricians in residential medication reviews. Setting Long term care facilities in Australia. Method Twenty vignettes of aged care residents were prepared and independently reviewed by five pharmacists and five geriatricians using a telehealth platform to record their recommendations for medications. The geriatricians were subsequently asked to re-consider their recommendations after being provided with a pharmacist's report. Main outcome measure The level of agreement between pharmacists and between geriatricians, changes in the mean number of medications after pharmacists' and geriatricians' reviews, number of changes in geriatricians' recommendations after viewing a pharmacist's report, and pharmacists' and geriatricians' feedback. Results Both pharmacists and geriatricians had fair agreement about their recommendations for medications (kappa of 0.30 and 0.31 respectively). The mean number of medications over 20 cases was significantly reduced from a baseline of 14.9 to 13.4 by pharmacists, and to 12.3 by geriatricians after their reviews. There was disagreement between geriatricians and pharmacists on 430/1485 (29%) recommendations on medications; after viewing a pharmacist's report, geriatricians changed their mind in 51 occasions. Geriatricians found the pharmacist report useful in 72% of the cases. The majority of the pharmacists (4/5) were prepared to use the online system routinely. Conclusion The tested telehealth platform has the potential of being used as a part of routine practice to improve accessibility of the service and to enable synchronous collaboration among healthcare professionals.

Interventions to Optimise Prescribing in Older People with Dementia: A Systematic Review.

BACKGROUND: Older adults living with dementia may have a higher risk of medication toxicity than those without dementia. Optimising prescribing in this group of people is a critically important yet challenging process. OBJECTIVE: Our aim was to systematically review the evidence for the effectiveness of interventions for optimising prescribing in older people with dementia. METHODS: This systematic review searched the Pubmed, Embase, CINAHL, PsycINFO and Cochrane Library electronic databases for studies that evaluated relevant interventions. Experimental, quasi-experimental and observational studies published in English prior to August 2018 were included. Data were synthesised at a narrative level. RESULTS: The 18 studies accepted for review included seven randomised, two nonrandomised controlled, five quasi-experimental and four observational studies. Half the studies were conducted in nursing homes and the other half in hospital and community settings. There was great variability in the interventions and outcomes reported and a meta-analysis was not feasible. The three randomised and four nonrandomised studies examining medication appropriateness all reported improvements on at least one measure of the outcome. Six studies reported on interventions that identified and resolved drug-related problems. The results for other outcomes, including the number of medications (10 studies), healthcare utilisation (7 studies), mortality (7 studies), quality of life (3 studies) and falls (3 studies), were mixed and difficult to synthesise because of variability in the study design and measures used. CONCLUSION: Emerging evidence suggests that interventions in older people with dementia may have positive effects on medication appropriateness and resolution of drug-related problems; however, whether optimisation of medication results in clinically meaningful outcomes remains uncertain.