Enhancing recruitment of individuals living with frailty, multimorbidity and cognitive impairment to Parkinson's research: experiences from the PRIME-UK cross-sectional study.

BACKGROUND AND OBJECTIVES: People with parkinsonism who are older, living in a care home, with frailty, multimorbidity or impaired capacity to consent are under-represented in research, limiting its generalisability. We aimed to evaluate more inclusive recruitment strategies. METHODS: From one UK centre, we invited people with parkinsonism to participate in a cross-sectional study. Postal invitations were followed by telephone reminders and additional support to facilitate participation. Personal consultees provided information on the views regarding research participation of adults with impaired capacity. These approaches were evaluated: (i) using external data from the Parkinson's Real World Impact assesSMent (PRISM) study and Clinical Practice Research Datalink (CPRD), a sample of all cases in UK primary care, and (ii) comparing those recruited with or without intensive engagement. RESULTS: We approached 1,032 eligible patients, of whom 542 (53%) consented and 477 (46%) returned questionnaires. The gender ratio in PRIME-UK (65% male) closely matched CPRD (61% male), unlike in the PRISM sample (46%). Mean age of PRIME participants was 75.9 (SD 8.5) years, compared to 75.3 (9.5) and 65.4 (8.9) years for CPRD and PRISM, respectively. More intensive engagement enhanced recruitment of women (13.3%; 95% CI 3.8, 22.9%; P = 0.005), care home residents (6.2%; 1.1, 11.2%; P = 0.004), patients diagnosed with atypical parkinsonism (13.7%; 5.4, 19.9%; P < 0.001), and those with a higher frailty score (mean score 0.2, 0.1, 0.2; P < 0.001). CONCLUSIONS: These recruitment strategies resulted in a less biased and more representative sample, with greater inclusion of older people with more complex parkinsonism.

Updating the British Geriatrics Society recommended undergraduate curriculum in geriatric medicine: a curriculum mapping and nominal group technique study.

BACKGROUND: medical education must adapt to meet the challenges and demands of an ageing population, ensuring that graduates are equipped to look after older patients with complex health and social care needs. Recommended curricula in geriatric medicine in the United Kingdom and Europe offer guidance for optimal undergraduate education in ageing. The UK version, written by the British Geriatrics Society (BGS), requires updating to take account of innovations in the specialty, changing guidance from the General Medical Council (GMC), and the need to support medical schools preparing for the introduction of the national Medical Licensing Assessment (MLA). METHODS: the BGS recommended curriculum was mapped to the most recent European curriculum (2014) and the MLA content map, to compare and contrast between current recommendations and nationally mandated guidance. These maps were used to guide discussion through a virtual Nominal Group Technique (NGT), including 21 expert stakeholders, to agree consensus on the updated BGS curriculum. RESULTS: the curriculum has been re-structured into seven sections, each with 1-2 overarching learning outcomes (LOs) that are expanded in multiple sub-LOs. Crucially, the curriculum now reflects the updated GMC/MLA requirements, having incorporated items flagged as missing in the mapping stages. CONCLUSION: the combined mapping exercise and NGT have enabled appropriate alignment and benchmarking of the UK national curriculum. These recommendations will help to standardise and enhance teaching and learning around the care of older persons with complexity.

Including older people in health and social care research: best practice recommendations based on the INCLUDE framework.

BACKGROUND: Older people are often explicitly or implicitly excluded from research, in particular clinical trials. This means that study findings may not be applicable to them, or that older people may not be offered treatments due to an absence of evidence. AIMS: The aim of this work was to develop recommendations to guide all research relevant to older people. METHODS: A diverse stakeholder group identified barriers and solutions to including older people in research. In parallel, a rapid literature review of published papers was undertaken to identify existing papers on the inclusion of older people in research. The findings were synthesised and mapped onto a socio-ecological model. From the synthesis we identified themes that were developed into initial recommendations that were iteratively refined with the stakeholder group. RESULTS: A range of individual, interpersonal, organisational, community and policy factors impact on the inclusion of older people in research. A total of 14 recommendations were developed such as removing upper age limits and comorbidity exclusions, involving older people, advocates and health and social care professionals with expertise in ageing in designing the research, and considering flexible or alternative approaches to data collection to maximise opportunities for participation. We also developed four questions that may guide those developing, reviewing and funding research that is inclusive of older people. CONCLUSION: Our recommendations provide up to date, practical advice on ways to improve the inclusion of older people in health and care research.

Identification of Legacy and Active Sources of Metal Contamination in Soils in Brooklyn, NY.

The purpose of this study was to examine the spatial distribution and potential anthropogenic sources of lead (Pb), zinc (Zn), copper (Cu), manganese (Mn), and iron (Fe) in surface soils throughout Brooklyn, NY. We collected soil samples (n = 1,373) from 176 different New York City parks. Samples were analyzed ex-situ using a portable X-ray fluorescence with a subset of samples laboratory confirmed. The effect of multiple sources on concentrations were determined by multivariable linear regression with generalized estimating equations. Median concentrations of Pb, Zn, Cu, Fe, and Mn were 108 ppm, 145 ppm, 49 ppm, 14,034 ppm, and 279 ppm, respectively. All metals were significantly correlated with one another (p < 0.001), with the strength of the correlation ranging from a low of approximately ρ = 0.3 (Pb-Mn and Zn-Mn) to a high of ρ = 0.7 (Pb-Cu). In final multivariate modeling significant association were observed between scrap yards and Mn concentration (ß = 0.075, 0.019), National Priorities List (NPL) sites and Pb, Fe and Mn (ß = 0.134, p = 0.004; ß = 0.038, p = 0.014; ß = 0.057, p = 0.037, respectively), and bridges nearby and Pb and Zn (ß = 0.106, p = 0.003; ß = 0.076, p = 0.026, respectively). Although manufacturing and industry have mostly left the area, smaller scrap metal recyclers are abundant and associated with increased Cu and Mn soil concentrations. In addition, NPL sites contributed to increased concentrations of all five metals within 800 m. Roadways have long been established to be sources of urban pollution; however, in our study we also found the presence of bridges within 800 m were also strongly predictive of increased Pb, Cu, and Zn concentrations.

Wearable and Portable GPS Solutions for Monitoring Mobility in Dementia: A Systematic Review.

Dementia is the most common neurodegenerative disorder globally. Disease progression is marked by declining cognitive function accompanied by changes in mobility. Increased sedentary behaviour and, conversely, wandering and becoming lost are common. Global positioning system (GPS) solutions are increasingly used by caregivers to locate missing people with dementia (PwD) but also offer a non-invasive means of monitoring mobility patterns in PwD. We performed a systematic search across five databases to identify papers published since 2000, where wearable or portable GPS was used to monitor mobility in patients with common dementias or mild cognitive impairment (MCI). Disease and GPS-specific vocabulary were searched singly, and then in combination, identifying 3004 papers. Following deduplication, we screened 1972 papers and retained 17 studies after a full-text review. Only 1/17 studies used a wrist-worn GPS solution, while all others were variously located on the patient. We characterised the studies using a conceptual framework, finding marked heterogeneity in the number and complexity of reported GPS-derived mobility outcomes. Duration was the most frequently reported category of mobility reported (15/17), followed by out of home (14/17), and stop and trajectory (both 10/17). Future research would benefit from greater standardisation and harmonisation of reporting which would enable GPS-derived measures of mobility to be incorporated more robustly into clinical trials.

Neuromodulation for Storage Lower Urinary Tract Symptoms in Parkinson Disease: A Systematic Review.

BACKGROUND: Bladder symptoms are common in Parkinson disease (PD), affecting quality of life. Medications commonly used such as antimuscarinics can cause frequently intolerable side effects, and therefore, new, better tolerated approaches are needed. Neuromodulation techniques have an established role in urologic disorders; these techniques include tibial nerve stimulation (TNS) and sacral neuromodulation (SNM), which are localized therapies lacking the side effects associated with medication. OBJECTIVES: This study aimed to undertake a systematic review of the literature reporting the use of neuromodulation techniques for the treatment of bladder symptoms in PD and related conditions. MATERIALS AND METHODS: A systematic search of data bases was conducted including MEDLINE, CENTRAL, and Web of Science. Studies were required to present specific outcomes for individuals with PD for neuromodulation interventions. RESULTS: Ten primary studies were identified concerning detailed outcomes of neuromodulation on bladder symptoms in PD, including seven for TNS, one for SNM, and one using transcranial magnetic stimulation (TMS). Two further mixed cohort studies documented minimal data on individuals with PD. All studies demonstrated benefit in a range of outcome measures following neuromodulation. Two randomized sham-controlled studies were carried out using TNS, with one clearly demonstrating superiority over sham, although difficulties with achieving believable yet ineffective sham treatment are highlighted. Further studies reported limited, uncontrolled outcomes of SNM in patients with PD, demonstrating benefit. CONCLUSIONS: Evidence from case series suggests benefit from TNS in PD, with limited literature on SNM or TMS. Placebo effect from neuromodulation is a concern, and only limited controlled data exist. Future well-designed and sham-controlled studies need to be completed to provide definitive data on the benefit of neuromodulation in PD. Definitively proving the utility of a neuromodulation modality will allow better treatment of bladder symptoms without the need for pharmacologic measures that cause side effects.

Rationale and design to evaluate the PRIME Parkinson care model: a prospective observational evaluation of proactive, integrated and patient-centred Parkinson care in The Netherlands (PRIME-NL).

BACKGROUND: Culminating evidence shows that current care does not optimally meet the needs of persons with parkinsonism, their carers and healthcare professionals. Recently, a new model of care was developed to address the limitations of usual care: Proactive and Integrated Management and Empowerment in Parkinson's Disease (PRIME Parkinson). From 2021 onwards, PRIME Parkinson care will replace usual care in a well-defined region in The Netherlands. The utility of PRIME Parkinson care will be evaluated on a single primary endpoint (parkinsonism-related complications), which reflects the health of people with parkinsonism. Furthermore, several secondary endpoints will be measured for four dimensions: health, patient and carer experience, healthcare professional experience, and cost of healthcare. The reference will be usual care, which will be continued in other regions in The Netherlands. METHODS: This is a prospective observational study which will run from January 1, 2020 until December 31, 2023. Before the new model of care will replace the usual care in the PRIME Parkinson care region all baseline assessments will take place. Outcomes will be informed by two data sources. We will use healthcare claims-based data to evaluate the primary endpoint, and costs of healthcare, in all persons with parkinsonism receiving PRIME Parkinson care (estimated number: 2,000) and all persons with parkinsonism receiving usual care in the other parts of The Netherlands (estimated number: 48,000). We will also evaluate secondary endpoints by performing annual questionnaire-based assessments. These assessments will be administered to a subsample across both regions (estimated numbers: 1,200 persons with parkinsonism, 600 carers and 250 healthcare professionals). DISCUSSION: This prospective cohort study will evaluate the utility of a novel integrated model of care for persons with parkinsonism in The Netherlands. We anticipate that the results of this study will also provide insight for the delivery of care to persons with parkinsonism in other regions and may inform the design of a similar model for other chronic health conditions.

Wearable GPS and Accelerometer Technologies for Monitoring Mobility and Physical Activity in Neurodegenerative Disorders: A Systematic Review.

Neurodegenerative disorders (NDDs) constitute an increasing global burden and can significantly impair an individual's mobility, physical activity (PA), and independence. Remote monitoring has been difficult without relying on diaries/questionnaires which are more challenging for people with dementia to complete. Wearable global positioning system (GPS) sensors and accelerometers present a cost-effective and noninvasive way to passively monitor mobility and PA. In addition, changes in sensor-derived outcomes (such as walking behaviour, sedentary, and active activity) may serve as potential biomarkers of disease onset, progression, and response to treatment. We performed a systematic search across four databases to identify papers published within the past 5 years, in which wearable GPS or accelerometers were used to monitor mobility or PA in patients with common NDDs (Parkinson's disease, Alzheimer's disease, motor neuron diseases/amyotrophic lateral sclerosis, vascular parkinsonism, and vascular dementia). Disease and technology-specific vocabulary were searched singly, and then in combination, identifying 4985 papers. Following deduplication, we screened 3115 papers and retained 28 studies following a full text review. One study used wearable GPS and accelerometers, while 27 studies used solely accelerometers in NDDs. GPS-derived measures had been validated against current gold standard measures in one Parkinson's cohort, suggesting that the technology may be applicable to other NDDs. In contrast, accelerometers are widely utilised in NDDs and have been operationalised in well-designed clinical trials.

Driving in Parkinson's disease: a retrospective study of driving and mobility assessments.

BACKGROUND: To guide decision-making about driving ability, some patients with Parkinson's disease (PD) undergo specialist driving assessment. However, decisions about driving safety in most patients need to be made without this definitive test. There is no consensus on what predicts unsafe driving in PD nor a validated prediction tool to guide clinician decision-making and the need to refer for further assessment. OBJECTIVES: To describe the characteristics of patients with PD assessed at a Driving Mobility Centre and investigate factors that predict driving assessment outcome. METHODS: Retrospective cohort study of patients with PD assessed between 2012 and 2016. Descriptive analyses and logistic models to determine factors predicting a negative outcome. RESULTS: There were 86 assessments of patients with PD. The mean age was 70 years (±9.2), 86% were male, median disease duration 7 years (interquartile range 5-12.5 years) and 59% were referred by the Driver and Vehicle Licensing Agency. In total, 62% had a negative 'not drive' outcome. The Rookwood Driving Battery (RDB), depth of vision deficit, usual driving frequency, age, duration license held and response time were all predictors in univariable analysis. The RDB was the best predictor of assessment failure, conditional on other variables in a backward stepwise model (odds ratio 1.29; 95% confidence interval 1.05, 1.60; P = 0.015). CONCLUSIONS: This is the first study to describe patients with PD undergoing driving assessments in the UK. In this population, RDB performance was the best predictor of outcome. Future prospective studies are required to better determine predictors of driving ability to guide development of prediction tools for implementation into clinical practice.

COVID-19 in older people: a rapid clinical review.

INTRODUCTION: the COVID-19 pandemic poses a high risk to older people. The aim of this article is to provide a rapid overview of the COVID-19 literature, with a specific focus on older adults. We frame our findings within an overview of the disease and have also evaluated the inclusion of older people within forthcoming clinical trials. METHODS: we searched PubMed and bioRxiv/medRxiv to identify English language papers describing the testing, treatment and prognosis of COVID-19. PubMed and bioRxiv/medRxiv searches took place on 20 and 24 March 2020, respectively. RESULTS: screening of over 1,100 peer-reviewed and pre-print papers yielded n = 22 on COVID-19 testing, n = 15 on treatment and n = 13 on prognosis. Viral polymerase chain reaction (PCR) and serology are the mainstays of testing, but a positive diagnosis may be increasingly supported by radiological findings. The current evidence for the effectiveness of antiviral, corticosteroid and immunotherapies is inconclusive, although trial data are largely based on younger people. In addition to age, male gender and comorbidities, specific laboratory and radiology findings are important prognostic factors. Evidence suggests that social distancing policies could have important negative consequences, particularly if in place for an extended period. CONCLUSION: given the established association between increasing age and poor prognosis in COVID-19, we anticipate that this rapid review of the current and emergent evidence might form a basis on which future work can be established. Exclusion of older people, particularly those with comorbidities, from clinical trials is well recognised and is potentially being perpetuated in the field of current COVID-19 research.

Rural-urban differences in the mental health of perinatal women: a UK-based cross-sectional study.

BACKGROUND: International data suggest that living in a rural area is associated with an increased risk of perinatal mental illness. This study tested the association between rurality and risk for two mental illnesses prevalent in perinatal women - depression and anxiety. METHODS: Using a cross-sectional design, antenatal and postnatal women were approached by healthcare professionals and through other networks in a county in Northern England (UK). After providing informed consent, women completed a questionnaire where they indicated their postcode (used to determine rural-urban status) and completed three outcome measures: the Edinburgh Postnatal Depression Scale (EPDS), the Whooley questions (depression measure), and the Generalised Anxiety Disorder 2-item (GAD-2). Logistic regression models were developed, both unadjusted and adjusted for potential confounders, including socioeconomic status, social support and perinatal stage. RESULTS: Two hundred ninety-five participants provided valid data. Women in rural areas (n = 130) were mostly comparable to their urban counterparts (n = 165). Risk for depression and/or anxiety was found to be higher in the rural group across all models: unadjusted OR 1.67 (0.42) 95% CI 1.03 to 2.72, p = .038. This difference though indicative did not reach statistical significance after adjusting for socioeconomic status and perinatal stage (OR 1.57 (0.40), 95% CI 0.95 to 2.58, p = .078), and for social support (OR 1.65 (0.46), 95% CI 0.96 to 2.84, p = .070). CONCLUSIONS: Data suggested that women in rural areas were at higher risk of depression and anxiety than their urban counterparts. Further work should be undertaken to corroborate these findings and investigate the underlying factors. This will help inform future interventions and the allocation of perinatal services to where they are most needed.

A Delphi study to build consensus on the definition and use of big data in obesity research.

BACKGROUND: 'Big data' has great potential to help address the global health challenge of obesity. However, lack of clarity with regard to the definition of big data and frameworks for effectively using big data in the context of obesity research may be hindering progress. The aim of this study was to establish agreed approaches for the use of big data in obesity-related research. METHODS: A Delphi method of consensus development was used, comprising three survey rounds. In Round 1, participants were asked to rate agreement/disagreement with 77 statements across seven domains relating to definitions of, and approaches to, using big data in the context of obesity research. Participants were also asked to contribute further ideas in relation to these topics, which were incorporated as new statements (n = 8) in Round 2. In Rounds 2 and 3 participants re-appraised their ratings in view of the group consensus. RESULTS: Ninety-six experts active in obesity-related research were invited to participate. Of these, 36/96 completed Round 1 (37.5% response rate), 29/36 completed Round 2 (80.6% response rate) and 26/29 completed Round 3 (89.7% response rate). Consensus (defined as > 70% agreement) was achieved for 90.6% (n = 77) of statements, with 100% consensus achieved for the Definition of Big Data, Data Governance, and Quality and Inference domains. CONCLUSIONS: Experts agreed that big data was more nuanced than the oft-cited definition of 'volume, variety and velocity', and includes quantitative, qualitative, observational or intervention data from a range of sources that have been collected for research or other purposes. Experts repeatedly called for third party action, for example to develop frameworks for reporting and ethics, to clarify data governance requirements, to support training and skill development and to facilitate sharing of big data. Further advocacy will be required to encourage organisations to adopt these roles.

Acute inability to mobilise resulting from probable donepezil-induced myoclonus.

Donepezil is a commonly prescribed cholinesterase inhibitor in Alzheimer's dementia. We present a case of probable donepezil-induced generalised myoclonus causing total inability to mobilise in a 93-year-old woman.

Securing systems leadership by local government through health and wellbeing strategies.

Background: The aim of this study was to strengthen Health and Wellbeing Strategies (HWSs) by identifying potential areas for system leadership across local authorities in relation to specific aspects of health/illness, wider determinants of health and transformational change management. Method: The work involved a document analysis of strengths of the first 12 HWSs produced in the North East of England applying principles of appreciative inquiry (AI), followed by a knowledge-to-action group approach with stakeholders. A summative event resulted in Health and Wellbeing Board (HWB) members identifying potential areas for collaboration. Results: The study identified diverse examples of good practice, and considerable consensus in terms of key priorities, both wider determinants such as employment, transport and housing, and subject areas such as lifestyle issues and children having the best start in life. There was agreement in principle to work across local authority boundaries, with academic partners. Consideration of HWSs as part of a complex adaptive system was welcomed by HWB Members. Conclusions: Collaborative working across HWBs could strengthen the effectiveness of HWSs in relation to inequalities in health, place-shaping and wider determinants of wellbeing. The co-production of identified areas to work toward health improvement was successful.

The Experiences of Young Complainant Witnesses in Criminal Court Trials for Sexual Offences.

For effective provision of justice it is important that young witnesses are involved in criminal trials, yet participation may be detrimental to their well-being and presents challenges for gaining full and accurate evidence from them. Innovations in court processes intended to support the well-being of young witnesses should, amongst other considerations, be informed by the perspectives and experiences of those whom they are intended to assist. The participants in the current study consisted of young complainant witnesses who were involved in criminal court trials for sexual offences, along with their parents or caregivers. Semi-structured interviews with individual participants were conducted. Audio recordings of interviews were then transcribed and analysed using thematic analysis. Nine themes were identified in the data: (1) pre-trial delay makes everything worse, (2) uncertainty is difficult and being prepared is important, (3) cross-examination is stressful, (4) having a voice is a positive aspect of the trial, (5) the possibility of seeing the defendant is stressful, (6) for parents, putting on a brave face and being a supporter is challenging, (7) young witnesses feel exposed by the court process and family members feel exposed to details of the offending, (8) support is critical, and (9) families place importance on the verdict and sentencing. The findings are considered within the New Zealand context as well as other jurisdictions, and recommendations are made.

Ciprofloxacin-associated bilateral iliopsoas tendon rupture: a case report.

Fluoroquinolone use is associated with the development of tendinopathy, most commonly affecting the Achilles tendon. Here we present the first reported case of bilateral iliopsoas tendon rupture associated with prolonged ciprofloxacin use. This older woman presented with non-traumatic, sudden onset hip pain which was diagnosed as a right iliopsoas rupture on MRI. Despite stopping ciprofloxacin, she went on to develop rupture of the contralateral iliopsoas tendon. This case highlights the time lag between fluoroquinolone use and susceptibility to this rare but important complication.

Assessment and management of fracture risk in patients with Parkinson's disease.

Parkinson's disease (PD) is associated with substantially increased fracture risk, particularly hip fracture, which can occur relatively early in the course of PD. Despite this, current national clinical guidelines for PD fail to adequately address fracture risk assessment or the management of bone health. We appraise the evidence supporting bone health management in PD and propose a PD-specific algorithm for the fracture risk assessment and the management of bone health in patients with PD and related movement disorders. The algorithm considers (i) calcium and vitamin D replacement and maintenance, (ii) quantification of prior falls and fractures, (iii) calculation of 10-year major osteoporotic and hip fracture risks using Qfracture, (iv) application of fracture risk thresholds, which if fracture risk is high (v) prompts anti-resorptive treatment, with or without dual X-ray absorptiometry, and if low (vi) prompts re-assessment with FRAX and application of National Osteoporosis Guidelines Group (NOGG) guidance. A range of anti-resorptive agents are now available to treat osteoporosis; we review their use from the specific perspective of a clinician managing a patient population with PD. In conclusion, our current evidence base supports updating of guidelines globally concerning the management of PD, which presently fail to adequately address bone health.

Acceptability of delivery of dietary advice in the dentistry setting to address obesity in pre-school children: a case study of the Common Risk Factor Approach.

OBJECTIVE: The Common Risk Factor Approach proposes that public health efforts can be improved by multiple agencies working together on a shared risk factor. The present study aimed to assess the acceptability to parents, dental practice staff and commissioners of the delivery of dietary advice in the dentistry setting in order to address obesity. DESIGN: Semi-structured focus groups with dental practice staff and one-to-one interviews with parents of pre-school children and public health commissioners involved in an oral health promotion initiative delivering dietary advice in dental surgeries. Data were analysed using the Framework Approach. SETTING: General dental practice surgeries and pre-schools in areas of high deprivation in north-east England. SUBJECTS: Parents (n 4), dental practice staff (n 23) and one commissioner. RESULTS: All participants found acceptable the concept of delivering public health messages in non-conventional settings. Dental practice staff were concerned about the potential for conflicting messages and deprioritisation of oral health advice, and they identified practical barriers to delivery, such as lack of training. Parents were very apprehensive about the potential of such approaches to stigmatise overweight children, including bullying. Uncertainty over the causes of obesity led to confusion about its solutions and the roles of public health and health care. CONCLUSIONS: Major concerns about the implementation of the Common Risk Factor Approach were raised by parents and dental practice staff. Specific dietary guidance for both oral health and healthy weight, as well as further research into issues of suitability, feasibility and stigmatisation, are needed.