Provision of palliative and end-of-life care in UK care homes during the COVID-19 pandemic: A mixed methods observational study with implications for policy.

Introduction: Little consideration has been given to how the provision of palliative and end-of-life care in care homes was affected by COVID-19. The aims of this study were to: (i) investigate the response of UK care homes in meeting the rapidly increasing need for palliative and end-of-life care during the COVID-19 pandemic and (ii) propose policy recommendations for strengthening the provision of palliative and end-of-life care within care homes. Materials and methods: A mixed methods observational study was conducted, which incorporated (i) an online cross-sectional survey of UK care homes and (ii) qualitative interviews with care home practitioners. Participants for the survey were recruited between April and September 2021. Survey participants indicating availability to participate in an interview were recruited using a purposive sampling approach between June and October 2021. Data were integrated through analytic triangulation in which we sought areas of convergence, divergence, and complementarity. Results: There were 107 responses to the survey and 27 interviews. We found that (i) relationship-centered care is crucial to high-quality palliative and end-of-life care within care homes, but this was disrupted during the pandemic. (ii) Care homes' ability to maintain high-quality relationship-centered care required key "pillars" being in place: integration with external healthcare systems, digital inclusion, and a supported workforce. Inequities within the care home sector meant that in some services these pillars were compromised, and relationship-centered care suffered. (iii) The provision of relationship-centered care was undermined by care home staff feeling that their efforts and expertise in delivering palliative and end-of-life care often went unrecognized/undervalued. Conclusion: Relationship-centered care is a key component of high-quality palliative and end-of-life care in care homes, but this was disrupted during the COVID-19 pandemic. We identify key policy priorities to equip care homes with the resources, capacity, and expertise needed to deliver palliative and end-of-life care: (i) integration within health and social care systems, (ii) digital inclusivity, (iii) workforce development, (iv) support for care home managers, and (v) addressing (dis)parities of esteem. These policy recommendations inform, extend, and align with policies and initiatives within the UK and internationally.

Defining the characteristics of intermediate care models including transitional care: an international Delphi study.

BACKGROUND: Although there is growing utilisation of intermediate care to improve the health and well-being of older adults with complex care needs, there is no international agreement on how it is defined, limiting comparability between studies and reducing the ability to scale effective interventions. AIM: To identify and define the characteristics of intermediate care models. METHODS: A scoping review, a modified two-round electronic Delphi study involving 27 multi-professional experts from 13 countries, and a virtual consensus meeting were conducted. RESULTS: Sixty-six records were included in the scoping review, which identified four main themes: transitions, components, benefits and interchangeability. These formed the basis of the first round of the Delphi survey. After Round 2, 16 statements were agreed, refined and collapsed further. Consensus was established for 10 statements addressing the definitions, purpose, target populations, approach to care and organisation of intermediate care models. DISCUSSION: There was agreement that intermediate care represents time-limited services which ensure continuity and quality of care, promote recovery, restore independence and confidence at the interface between home and acute services, with transitional care representing a subset of intermediate care. Models are best delivered by an interdisciplinary team within an integrated health and social care system where a single contact point optimises service access, communication and coordination. CONCLUSIONS: This study identified key defining features of intermediate care to improve understanding and to support comparisons between models and studies evaluating them. More research is required to develop operational definitions for use in different healthcare systems.

The politics of frailty.

The world population is ageing because of falling fertility and improved life expectancy. Knowing this has not helped governments develop sustainable health and care policies because the underlying causes and impacts of population ageing remain poorly understood. Planning using only population age structure does not account for uneven geographical distribution of older people, their health characteristics, functional needs or lived experiences. English National Health Service (NHS) policy has previously focused on arbitrary age segmentation, failing to capture the origins of cumulative disease and functional burden and missing the opportunity to incorporate wider determinants of health into prevention of poor-quality ageing. This is despite growing international evidence that adults living in places with low per capita income and educational attainment experience a higher burden of age-related disease. Lack of a credible ageing narrative and good quality population health data have contributed to a focus on single disease prevention, rather than life course disease aggregation and its personal impacts. However, a fully explicated health and care narrative incorporating frailty does now give some cause for optimism. In 2017, England became the first country to characterise and systematically identify frailty as a long-term treatable health condition. This was coincident with a UK Government's Industrial Strategy targeting societal ageing. In 2019, the English NHS published a funded long-term plan including a major programme focused on ageing well. Policy makers, health leaders and clinicians must not squander these opportunities but instead pursue frailty prevention and intervention to improve the quality of population ageing.

Nutrition, older people and the end of life.

Older patients are at increased risk of malnutrition, resulting in higher mortality and morbidity. It is important to address nutritional need early in order to prevent or mitigate these adverse outcomes. Decisions about nutrition and hydration for older people presenting with acute illness or evolving multiple long-term conditions present great difficulty to all involved. Clinicians are more likely to encounter such situations as the population of older people with frailty syndromes expands. The clinical evidence base to guide such decisions is sparse and largely unhelpful. Clinicians must recognise their role in these difficult decisions. In addition to familiarity with the clinical evidence base, they must be fully informed of the legal, professional and moral context of the decisions with which they are faced. Responsible clinicians have a professional duty to elicit, understand and weigh the views of their patient, and where necessary their representatives. This can only be undertaken through a process of facilitated patient choice utilising the available legal and professional decision-making frameworks. Any decision relating to clinically assisted nutrition and/or hydration in a frail older person who is considered to be nearing the end of their life must also include explicit consideration of the needs of that individual for formalised palliative care.

Rivastigmine in the treatment of delirium in older people: a pilot study.

BACKGROUND: Delirium is common in the elderly and is associated with high mortality and negative health outcomes. Reduced activity in the cholinergic system has been implicated in the pathogenesis of delirium. Cholinesterase inhibitors, which increase cholinergic activity, may therefore be beneficial in the treatment of delirium. METHODS: This is a double-blind, placebo-controlled randomized pilot study of the treatment of delirium with a cholinesterase inhibitor of patients admitted to hospital medical wards. Patients over the age of 65 years were identified as having delirium by the Confusion Assessment Method (CAM). Patients with delirium were randomized to receive rivastigmine 1.5 mg once a day increasing to 1.5 mg twice a day after seven days or an identical placebo (two tablets after seven days). RESULTS: Fifteen patients entered the trial; eight received rivastigmine and seven received placebo. All of the rivastigmine group, but only three of the placebo group, were negative for delirium on the CAM when they left the study and eventually discharged home. There was no significant difference in the duration of delirium between the two groups (rivastigmine group 6.3 days versus placebo group 9.9 days, p = 0.5, 95% confidence interval -15.6-8.4). CONCLUSIONS: The numbers of patients who screened positive for delirium was very small and as a result the sample size was too small to make any meaningful inferences about treatment of delirium. Despite the small numbers included in the study, there are some indicators that rivastigmine may be safe and effective in treating delirium.

Dental health of community-living older people attending secondary healthcare: a cross-sectional comparison between those with and without diagnosed mental illness.

BACKGROUND: Mental illness and cognitive impairment are risk factors for poor dental health. METHODS: We conducted a cross-sectional study to compare the dental health of older patients attending out-patient clinics and day hospitals of old age psychiatry services (the psychiatry group, n = 103) with those attending general/geriatric medical services (the medical group; n = 99). Those living in care homes, and those with diagnosed mental illness (in the medical group) were excluded. A registered mental health nurse assessed mental and general health using validated and previously published instruments. A registered dentist made an independent assessment of dental health (examination to assess oral pathology, status of remaining teeth, and dentures) and made an overall judgment about whether the patient needed any dental treatment (a "normative" need). RESULTS: The normative need for dental treatment was significantly higher among the psychiatry group compared to the medical group (85% vs 52%; p<0.001); even after taking account of the effect of age, gender, teeth status, physical comorbidity, cognition, depressive symptoms, and overall mental and social health [adjusted odds ratio, OR (95% confidence interval): 4.32 (2.09, 8.91)]. The presence of any natural remaining teeth [OR: 4.44 (2.10, 9.42)] and Barthel Index [OR: 0.96 (0.93, 0.99)] were the two other independent predictors of the need for treatment. CONCLUSION: Dental problems are common in community-living older people, especially those with some natural remaining teeth and those with mental illness. There is a need to develop integrated mental health and dental care services for older people with emphasis on prevention of dental problems.

Care home medicine in the UK--in from the cold.

The quality of care within care homes comes under frequent media scrutiny, and is underpinned by the medical support to the staff. In the UK, medical care to care homes is provided by general practitioners. A GP is likely to have patients in many homes, and each home relates to many GPs. The growing complexity of patients in care requires proactive models of care delivered by those with an understanding of care home medicine. A range of innovative models of medical care are emerging across the UK which have the potential to improve the standard of care in homes, and reduce inappropriate use of secondary care admissions. These models are described, and the need for them to be subjected to evaluation.

Potent inhibition of huntingtin aggregation and cytotoxicity by a disulfide bond-free single-domain intracellular antibody.

Huntington's disease (HD) is a progressive neurodegenerative disorder caused by an expansion in the number of polyglutamine-encoding CAG repeats in the gene that encodes the huntingtin (htt) protein. A property of the mutant protein that is intimately involved in the development of the disease is the propensity of the glutamine-expanded protein to misfold and generate an N-terminal proteolytic htt fragment that is toxic and prone to aggregation. Intracellular antibodies (intrabodies) against htt have been shown to reduce htt aggregation by binding to the toxic fragment and inactivating it or preventing its misfolding. Intrabodies may therefore be a useful gene-therapy approach to treatment of the disease. However, high levels of intrabody expression have been required to obtain even limited reductions in aggregation. We have engineered a single-domain intracellular antibody against htt for robust aggregation inhibition at low expression levels by increasing its affinity in the absence of a disulfide bond. Furthermore, the engineered intrabody variable light-chain (V(L))12.3, rescued toxicity in a neuronal model of HD. We also found that V(L)12.3 inhibited aggregation and toxicity in a Saccharomyces cerevisiae model of HD. V(L)12.3 is significantly more potent than earlier anti-htt intrabodies and is a potential candidate for gene therapy treatment for HD. To our knowledge, this is the first attempt to improve affinity in the absence of a disulfide bond to improve intrabody function. The demonstrated importance of disulfide bond-independent binding for intrabody potency suggests a generally applicable approach to the development of effective intrabodies against other intracellular targets.