From bare life and necropolitics to a feminist care ethic: ageism in the COVID-19 pandemic and future directions.

This perspective paper begins with discussing how COVID-19 magnified the pre-pandemic 'bare life' conditions which exposed older people's lives to risks and indignities in the health and social care system. Then, by using the concept of Necropolitics, the life and death decisions, based on age as a proxy measure for population health during the pandemic, are discussed. This discussion includes examples of 'exceptional' practices that were implemented in the UK during the first wave, including 'Do Not Resuscitate' orders, unsafe hospital discharges, not transferring to hospitals, and denying access to treatment for older people. It then goes on to renew the call for a feminist care ethic to be central to the ways in which our future health and social care systems are configured. Arguing for the need to politically reframe ageing, health and social care provision towards a radical alternative system that rethinks care relations and addresses inequality.

Consequences of 'conversations not had': insights into failures in communication affecting delays in hospital discharge for older people living with frailty.

OBJECTIVES: Older people living with frailty (OPLWF) are often unable to leave hospital even if they no longer need acute care. The aim of this study was to elicit the views of health care professionals in England on the barriers to effective discharge of OPLWF. METHODS: We conducted semi-structured interviews with hospital-based doctors and nurses with responsibility for discharging OPLWF from one large urban acute care hospital in England. The data were analysed using the constant comparative method. RESULTS: We conducted interviews with 17 doctors (12 senior doctors or consultants and 5 doctors in training) and six senior nurses. Some of our findings reflect well-known barriers to hospital discharge including service fragmentation, requiring skilled coordination that was often not available due to high volumes of work, and poor communication between staff from different organizations. Participants' accounts also referred to less frequently documented factors that affect decision making and the organization of patient discharges. These raised uncomfortable emotions and tensions that were often ignored or avoided. One participant referred to 'conversations not had', or failures in communication, because difficult topics about resuscitation, escalation of treatment and end-of-life care for OPLWF were not addressed. CONCLUSIONS: The consequences of not initiating important conversations about decisions relating to the end of life are potentially far reaching not only regarding reduced efficiency due to delayed discharges but also for patients' quality of life and care. As the population of older people is rising, this becomes a key priority for all practitioners in health and social care. Evidence to support practitioners, OPLWF and their families is needed to ensure that these vital conversations take place so that care at the end of life is humane and compassionate.

Objectively assessed physical activity and lower limb function and prospective associations with mortality and newly diagnosed disease in UK older adults: an OPAL four-year follow-up study.

BACKGROUND: Objective measures of physical activity and function with a diverse cohort of UK adults in their 70s and 80s were used to investigate relative risk of all-cause mortality and diagnoses of new diseases over a 4-year period. PARTICIPANTS: Two hundred and forty older adults were randomly recruited from 12 general practices in urban and suburban areas of a city in the United Kingdom. Follow-up included 213 of the baseline sample. METHODS: Socio-demographic variables, height and weight, and self-reported diagnosed diseases were recorded at baseline. Seven-day accelerometry was used to assess total physical activity, moderate-to-vigorous activity and sedentary time. A log recorded trips from home. Lower limb function was assessed using the Short Physical Performance Battery. Medical records were accessed on average 50 months post baseline, when new diseases and deaths were recorded. ANALYSES: ANOVAs were used to assess socio-demographic, physical activity and lower limb function group differences in diseases at baseline and new diseases during follow-up. Regression models were constructed to assess the prospective associations between physical activity and function with mortality and new disease. RESULTS: For every 1,000 steps walked per day, the risk of mortality was 36% lower (hazard ratios 0.64, 95% confidence interval (CI) 0.44-0.91, P=0.013). Low levels of moderate-to-vigorous physical activity (incident rate ratio (IRR) 1.67, 95% CI 1.04-2.68, P=0.030) and low frequency of trips from home (IRR 1.41, 95% CI 0.98-2.05, P=0.045) were associated with diagnoses of more new diseases. CONCLUSION: Physical activity should be supported for adults in their 70s and 80s, as it is associated with reduced risk of mortality and new disease development.

Can paramedics use FRAX (the WHO Fracture Risk Assessment Tool) to help GPs improve future fracture risk in patients who fall? Protocol for a randomised controlled feasibility study.

INTRODUCTION: Currently identification, and therefore, management of patients at risk of osteoporotic fracture in the UK is suboptimal. As the majority of patients who fracture have fallen, it follows that people who fall can usefully be targeted in any programme that aims to reduce osteoporotic fracture. Targeting vulnerable patients who are likely to benefit from intervention may help shift the management of fracture prevention into primary care, away from emergency departments. Paramedics who attend to patients who have fallen may be well placed to assess future fracture risk, using the Fracture Risk Assessment Tool (FRAX) and communicate that information directly to general practitioners (GPs). METHODS AND ANALYSIS: This feasibility study takes the form of a pragmatic, randomised controlled trial aimed at exploring and refining issues of study design, recruitment, retention, sample size and acceptability preceding a large-scale study with fracture as the end point. Patients (aged >50) who fall, call an ambulance, are attended by a study paramedic and give verbal consent will be asked FRAX and fall questions. Patients who subsequently formally consent to participation will be randomised to control (usual care) or intervention groups. Intervention will constitute transmission of calculated future fracture risk to the patients' GP with suitable, evidence-based recommendations for investigation or treatment. 3 months after the index fall, data (proportion of patients in each group undergoing investigation or starting new treatment, quality of life and health economic) will be collected and analysed using descriptive statistics. A nested qualitative study will explore issues of acceptability and study design with patients, paramedics and GPs. ETHICS AND DISSEMINATION: This protocol was approved by NRES Committee South Central Oxford C in October 2012. Research Ethics Committee ref.12/SC/0604. The study findings will be disseminated through peer-reviewed journals, conference presentations and local public events. A publication plan and authorship criteria have been preagreed. TRIAL REGISTRATION NUMBER ISRCTN: 36245726.

What works in 'real life' to facilitate home deaths and fewer hospital admissions for those at end of life?: results from a realist evaluation of new palliative care services in two English counties.

BACKGROUND: WE EVALUATED END OF LIFE CARE SERVICES IN TWO ENGLISH COUNTIES INCLUDING: coordination centres, telephone advice line, 'Discharge in Reach' nurses, a specialist community personal care team and community nurse educators. Elsewhere, we published findings detailing high family carer satisfaction and fewer hospital admissions, Accident and Emergency attendances and hospital deaths for service users compared to controls. The aim of this paper is to discuss what contributed to those outcomes. METHODS: Using realist evaluation, data collection included documentation (e.g. referral databases), 15 observations of services and interviews with 43 family carers and 105 professionals. Data were analysed using framework analysis, applying realist evaluation concepts. Findings were discussed at successive team meetings and further data was collected until team consensus was reached. RESULTS: Services 'worked' primarily for those with cancer with 'fast track' funding who were close to death. Factors contributing to success included services staffed with experienced palliative care professionals with dedicated (and sufficient) time for difficult conversations with family carers, patients and/or clinical colleagues about death and the practicalities of caring for the dying. Using their formal and informal knowledge of the local healthcare system, they accessed community resources to support homecare and delivered excellent services. This engendered confidence and reassurance for staff, family carers and patients, possibly contributing to less hospital admissions and A&E attendances and more home deaths. CONCLUSIONS: With demand for 24-hour end of life care growing and care provision fragmented across health and social care boundaries, services like these that cut across organisational sectors may become more important. They offer an overview to help navigate those desiring a home death through the system.

Objectively assessed physical activity and subsequent health service use of UK adults aged 70 and over: a four to five year follow up study.

OBJECTIVES: To examine the associations between volume and intensity of older peoples' physical activity, with their subsequent health service usage over the following four to five years. STUDY DESIGN: A prospective cohort design using baseline participant characteristics, objectively assessed physical activity and lower limb function provided by Project OPAL (Older People and Active Living). OPAL-PLUS provided data on numbers of primary care consultations, prescriptions, unplanned hospital admissions, and secondary care referrals, extracted from medical records for up to five years following the baseline OPAL data collection. PARTICIPANTS AND DATA COLLECTION: OPAL participants were a diverse sample of 240 older adults with a mean age of 78 years. They were recruited from 12 General Practitioner surgeries from low, middle, and high areas of deprivation in a city in the West of England. Primary care consultations, secondary care referrals, unplanned hospital admissions, number of prescriptions and new disease diagnoses were assessed for 213 (104 females) of the original 240 OPAL participants who had either consented to participate in OPAL-PLUS or already died during the follow-up period. RESULTS: In regression modelling, adjusted for socio-economic variables, existing disease, weight status, minutes of moderate-to-vigorous physical activity (MVPA) per day predicted subsequent numbers of prescriptions. Steps taken per day and MVPA also predicted unplanned hospital admissions, although the strength of the effect was reduced when further adjustment was made for lower limb function. CONCLUSIONS: Community-based programs are needed which are successful in engaging older adults in their late 70s and 80s in more walking, MVPA and activity that helps them avoid loss of physical function. There is a potential for cost savings to health services through reduced reliance on prescriptions and fewer unplanned hospital admissions.

Patients' experiences of participating in a large-scale trial of cognitive behavioural therapy for depression: a mixed methods study.

BACKGROUND: Adequate recruitment and retention rates are vital to achieving a successful randomized controlled trial. Historically this has been particularly challenging in mental health research. Few researchers have explored patients' reasons for taking part and remaining in a depression trial. OBJECTIVE: To explore patients' reasons for taking part and remaining in a trial that aimed to assess the effectiveness of cognitive behavioural therapy (CBT) as an adjunct to usual care for primary care patients with treatment resistant depression. METHOD: (i) DESIGN: Patients completed a short exit questionnaire about their experiences of taking part in the CoBalT trial. In addition, 40 semi-structured telephone interviews were conducted with a purposive sample of these patients to further explore their experiences. (ii) SETTING: General practices, England and Scotland. RESULTS: Of 469 patients randomized into the trial, 302 (64.4%) completed an exit questionnaire. The most frequently rated reason for taking part in the study were 'I was willing to try anything that might help me feel better' (66%). Patients indicated in interviews why they preferred follow-up data to be collected on a face-to-face basis rather than over the telephone. Some patients reported that taking part in the trial gave them a sense of self-worth and accomplishment. CONCLUSION: Patients felt they benefited from being in the trial because it enabled them to reflect on their feelings. For some, taking part increased their feelings of self-worth. These findings may be applicable to trials where feelings of inclusion and being valued are likely to promote continued participation.