What constitutes brilliant aged care? A qualitative study of practices that exceed expectation.

AIM: This study aimed to explore what constitutes brilliant aged care. BACKGROUND: Although many aged care services do not offer the care that older people and carers need and want, some perform better. Rather than focus on problems with aged care, this study examined brilliant aged care-practices that exceeded expectation. DESIGN: The methodology for this study was informed by grounded theory, underpinned by constructionism to socially construct meaning. METHODS: This study invited nominations for a Brilliant Award via a survey, and interviews with the nominees via web conference. After receiving survey responses from 10 nominators, interviews were conducted with 12 nominees. Data were analysed using reflexive thematic analysis and documented according to COREQ guidelines to optimise rigour and transparency. RESULTS: According to participants, brilliant aged care involved being relationally attuned to older people, a deep understanding of the older person, recognition of aged care as more than a job, innovative practices and permission to reprioritise. CONCLUSIONS: This study suggests that, in aged care, brilliance happens. It emphasises the importance of meaningful connections and relationships in aged care, where thoughtful acts acknowledge an older person's value and humanity as well as creativity and innovation. RELEVANCE TO CLINICAL PRACTICE: For those who manage and deliver aged care, the findings suggest that small practice changes can make a positive difference to older people. Brilliant aged care can involve acts of empathy; enthusiasm for aged care; innovative practices, even those that are small scale; and reprioritising workplace tasks to spend time with older people. For policymakers, this study highlights the need to recognise and raise the profile of the pockets of brilliance within the aged care sector. This might be achieved via awards and other initiatives that serve to celebrate and learn from brilliance in its myriad forms. PATIENT OR PUBLIC CONTRIBUTION: The nominees, who included carers, were invited to participate in workshops with other carers and older people to co-design a model of brilliant aged care, during which workshop participants discussed and critiqued the findings constructed from the data.

Clustering and Additive Effects of Nongenetic Risk Factors in Non-Autosomal-Dominant Degenerative and Vascular Young Onset Dementia.

INTRODUCTION: Both genetic and nongenetic factors contribute to the risk profile of young onset dementia (YOD), but risk factors often co-occur. This matched case-control study examined whether nongenetic risk factors cluster together, to inform targeted prevention efforts. METHODS: Ninety-six participants with non-autosomal-dominant degenerative and/or vascular YOD and 175 controls were recruited to 2 Australian epidemiological studies. Risk exposure was retrospectively self-reported and/or informant-reported. RESULTS: Each additional exposure increased the risk for YOD, though only where vascular dementia was included in the analysis. Cluster analysis identified 4 risk groups, one of which reported a high probability of exposure to all risks and a significantly higher risk for YOD. DISCUSSION: Results suggest that combinations of nongenetic risk factors confer more risk for young onset vascular dementia, and possibly primary degenerative YOD, than a single factor on its own. Compared with their same-age peers, some people with YOD experience a lifetime of risk exposure starting from early in life.

Early vertebroplasty within 3 weeks of fracture for acute painful vertebral osteoporotic fractures: subgroup analysis of the VAPOUR trial and review of the literature.

BACKGROUND: VAPOUR found vertebroplasty (V) more effective than placebo (P) in patients with severe pain and fracture duration less than 6 weeks. Exploratory analysis suggested that benefits were concentrated in the subgroup of patients with fractures ≤ 3-week duration. This difference may account for the three negative blinded trials that included few patients within this fracture time frame. PURPOSE: To assess the safety and efficacy of early vertebroplasty for acute painful vertebral osteoporotic fractures within 3 weeks of fracture onset in the VAPOUR study. METHODS: Spearman's rank log coefficients were calculated to reassess the relationship of pain reduction from vertebroplasty and fracture duration in the VAPOUR trial. We more fully report baseline and outcome data in patients with fractures ≤ 3-week duration. RESULTS: There were 46V and 47P patients with fractures ≤ 3-week duration. Baseline characteristics were similar. In total, 86 patients (41V, 45P) completed the 14-day questionnaire. The proportion of patients with reduction in pain from severe (NRS ≥ 7/10 was an inclusion requirement) to mild (NRS < 4) at 14 days was 21 (51%) V-group and 9 (20%) in the P-group (between-group difference 31 percentage points, 95% CI 12-50; p = 0.002). Early vertebroplasty provided greater reductions in mean NRS pain and Roland-Morris Disability. CONCLUSION: Analysis of this patient subgroup from the VAPOUR trial, in the context of other randomised trial evidence, suggests clinically significant benefits from early vertebroplasty if performed within 3 weeks of fracture. These slides can be retrieved from Electronic Supplementary Material.

Feasibility and potential effects of interdisciplinary home-based reablement program (I-HARP) for people with cognitive and functional decline: a pilot trial.

Objectives: To test feasibility and potential effects of the interdisciplinary Home-bAsed Reablement Program (I-HARP) that integrates evidence-based strategies and cognitive rehabilitation techniques into a dementia-specific, bio-behavioural-environmental intervention.Methods: A parallel-group randomised controlled pilot trial was conducted in Sydney, Australia, targeting community-dwelling people with amnestic mild cognitive impairment or mild/moderate stages of dementia and their carer (n = 18 dyads). I-HARP comprised: up to 12 home visits by registered nurse, occupational therapist, and psychologist, tailored to the individual client's needs;

Southcare Geriatric Flying Squad: an innovative Australian model providing acute care in residential aged care facilities.

This study reviews the outcomes of a model developed to improve the quality of care of residents living within residential aged care facilities (RACF). The Southcare Geriatric Flying Squad saw a total of 640 acutely unwell RACF residents over an 18-month period. Of these, 578 (90.3%) were managed in the RACF avoiding emergency department. Only 35 (5.5%) patients required emergency department transfer and 27 (4.2%) were directly admitted to a medical ward. The service may have reduced emergency presentations by offering rapid assessment and management, choice in place of treatment and level of interventions.

Diagnosis and management of hyponatraemia in the older patient.

Hyponatraemia (serum sodium concentration below 135 mmol/L) is the most common electrolyte disturbance and occurs commonly in older people. The causes can be complex to diagnose and treat and many published guidelines do not focus on the issues in an older patient group. Here, we are principally concerned with diagnosis and management of euvolaemic and hypervolaemic hyponatraemia in hospitalised patients over 70 years old. We also aim to increase awareness of hyponatraemia in residential aged care facilities and the community. Hyponatraemia can have many causes; in older people, chronic hyponatraemia can often be the result of medications used to treat chronic disease, particularly thiazide or thiazide-like drugs (such as indapamide) or drugs acting on the central nervous system. Where a reversible trigger (such as drug-induced hyponatraemia) can be identified, hyponatraemia may be treated relatively simply. Chronic hyponatraemia due to an irreversible cause will require ongoing treatment. Fluid restriction can be an effective therapy in dilutional hyponatraemia, although poor compliance and the burdensome nature of the restrictions are important considerations. Tolvaptan is an oral vasopressin receptor antagonist that can increase serum sodium concentrations by increasing electrolyte-free water excretion. Tolvaptan use is supported by clinical trial evidence in patients with hypervolaemic or euvolaemic hyponatraemia below 125 mmol/L. Clinical trial evidence also supports its use after a trial of fluid restriction in patients with symptomatic hyponatraemia above 125 mmol/L. The use of tolvaptan is affected by regulatory restriction of chronic therapy due to safety concern and the non-subsidised cost of treatment.

Safety and efficacy of vertebroplasty for acute painful osteoporotic fractures (VAPOUR): a multicentre, randomised, double-blind, placebo-controlled trial.

BACKGROUND: We hypothesised that vertebroplasty provides effective analgesia for patients with poorly controlled pain and osteoporotic spinal fractures of less than 6 weeks' duration. The effectiveness of vertebroplasty, using an adequate vertebral fill technique, in fractures of less than 6 weeks' duration has not been specifically assessed by previously published masked trials. METHODS: This was a multicentre, randomised, double-blind, placebo-controlled trial of vertebroplasty in four hospitals in Sydney, Australia. We recruited patients with one or two osteoporotic vertebral fractures of less than 6 weeks' duration and Numeric Rated Scale (NRS) back pain greater than or equal to 7 out of 10. We used an automated telephone randomisation service provided by the National Health and Medical Research Council to assign patients (1:1; stratified according to age, degree of vertebral compression, trauma, corticosteroid use, and hospital) to either vertebroplasty or placebo, immediately before the procedure. Patients received conscious sedation. Vertebroplasty was done with the adequate vertebral fill technique and the placebo procedure with simulated vertebroplasty. Follow-up was for 6 months. Outcome assessors and patients were masked to treatment allocation. The primary outcome was the proportion of patients with NRS pain below 4 out of 10 at 14 days post-intervention in the intention-to-treat population. This study is registered with ClinicalTrials.gov, number NCT01482793. FINDINGS: Between Nov 4, 2011, and Dec 5, 2014, 120 patients were enrolled. 61 patients were randomly assigned to vertebroplasty and 59 to placebo. 24 (44%) patients in the vertebroplasty group and 12 (21%) in the control group had an NRS pain score below 4 out of 10 at 14 days (between-group difference 23 percentage points, 95% CI 6-39; p=0·011). Three patients in each group died from causes judged unrelated to the procedure. There were two serious adverse events in each group, related to the procedure (vertebroplasty group) and the fracture (control group). INTERPRETATION: Vertebroplasty is superior to placebo intervention for pain reduction in patients with acute osteoporotic spinal fractures of less than 6 weeks' in duration. These findings will allow patients with acute painful fractures to have an additional means of pain management that is known to be effective. FUNDING: Education grant from CareFusion Corporation.

Time to diagnosis in young-onset dementia and its determinants: the INSPIRED study.

OBJECTIVE: The objective of this study is to identify factors determining the time to diagnosis for young-onset dementia (YOD), defined as dementia with symptom onset before age 65 years, by mapping the diagnostic pathways. METHODS: Participants were recruited via healthcare professionals, community support organisations or were self-referred. Information was obtained by interviews with the person with YOD and their carer, and medical record reviews. Clinical dementia diagnoses were independently ratified by consensus review. RESULTS: Participants included 88 people with YOD (mean age of onset = 55.4 years), due to Alzheimer's disease (AD) (53.4%, n = 47), frontotemporal dementia (FTD) (15.9%, n = 14) and other causes (30.7%, n = 27). Median time from symptom onset to first consultation was 2.3 years, to dementia diagnosis 3.2 years, to family awareness of dementia diagnosis 3.5 years and to final diagnosis of the type of dementia 4.7 years. Non-dementia diagnoses occurred in 48.9%, including depression (30.7%) and mild cognitive impairment (MCI) (17.0%). Participants with younger age of onset had significantly longer time to first consultation and family awareness of the dementia diagnosis. The time to dementia diagnosis was significantly longer when the participant presented with MCI or depression and when the dementia was other than AD or FTD. MCI was associated with significantly longer time to family awareness of dementia diagnosis. CONCLUSIONS: Factors impacting on time to diagnosis vary with the stage of diagnosis in YOD. Longer time to dementia diagnosis occurred in people who were younger at symptom onset, when MCI or depression was present, and in dementias other than AD and FTD. Copyright © 2016 John Wiley & Sons, Ltd.

Medium term effects of including manual therapy in a pulmonary rehabilitation program for chronic obstructive pulmonary disease (COPD): a randomized controlled pilot trial.

STUDY DESIGN: Randomized clinical trial. OBJECTIVE: To investigate the effect of including manual therapy (MT) in a pulmonary rehabilitation program for patients with chronic obstructive pulmonary disease (COPD). BACKGROUND: The primary source of exercise limitation in people with COPD is dyspnea. The dyspnea is partly caused by changes in chest wall mechanics, with an increase in chest wall rigidity (CWR) contributing to a decrease in lung function. As MT is known to increase joint mobility, administering MT to people with COPD carries with it the potential to influence CWR and lung function. METHODS: Thirty-three participants with COPD, aged between 55 and 70 years (mean = 65·5±4 years), were randomly assigned to three groups: pulmonary rehabilitation (PR) only, soft tissue therapy (ST) and PR, and ST, spinal manipulative therapy (SM), and PR. Outcome measures including forced expiratory volume in the 1st second (FEV1), forced vital capacity (FVC), 6-minute walking test (6MWT), St. George's respiratory questionnaire (SGRQ), and the hospital anxiety and depression (HAD) scale were recorded at 0, 8, 16, and 24 weeks. RESULTS: There was a significant difference in FVC between the three groups at 24 weeks (P = 0·04). For the ST+SM+PR group versus PR only the increase was 0·40 l (CI: 0·02, 0·79; P = 0·03). No major or moderate adverse events (AE) were reported following the administration of 131 ST and 272 SM interventions. DISCUSSION: The increase in FVC is a unique finding. Although the underlying mechanisms responsible for this outcome are not yet understood, the most likely explanation is the synergistic effect resulting from the combination of interventions. These results support the call for a larger clinical trial in the use of MT for COPD.

The Long-Term Benefit of Exercise With and Without Manual Therapy for Mild Chronic Obstructive Pulmonary Disease: A Randomized Controlled Trial.

PURPOSE: Chronic obstructive pulmonary disease (COPD) is characterized by decreasing exercise capacity and deteriorating quality of life (QoL). Recent evidence indicates that combining exercise with manual therapy (MT) delivers greater improvements in exercise capacity than exercise alone in moderate COPD. The aim of this study was to investigate whether this combination delivers similar results in mild COPD. METHODS: A total of 71 participants aged 50-65 yr with mild COPD were randomly allocated to two groups: exercise only (Ex) or MT plus exercise (MT + Ex). Both groups received 16 wk of exercise with the MT + Ex group also receiving 8 MT sessions. Lung function (forced vital capacity [FVC] and forced expiratory volume in the 1 st sec [FEV 1 ]), exercise capacity (6-min walk test [6MWT]), and QoL (St George's Respiratory Questionnaire [SGRQ] and Hospital Anxiety and Depression Scale [HADS]) were measured at baseline, 4, 8, 16, 24, 32, and 48 wk. RESULTS: Although there was no difference in the mean effect over time between groups for lung function (FEV 1 , P = .97; FVC, P = .98), exercise capacity (6MWT, P = .98), and QoL (SGRQ, P = .41; HADS anxiety, P = .52; and HADS depression, P = .06), there were clinically meaningful improvements at 48 wk for 6MWT (30 m; 95% CI, 10-51 m; P < .001), SGRQ (6.3 units; 95% CI, 2.5-10.0; P < .001), and HADS anxiety (1.5 units; 95% CI, 0.3-2.8 units; P = .006) across the entire cohort. CONCLUSIONS: While adding MT to Ex did not produce any additional benefits, exercise alone did deliver sustained modest improvements in exercise capacity and QoL in mild COPD.

Feasibility and Acceptability of Facilitated Advance Care Planning in Outpatient Clinics: A Qualitative Study of Patient and Caregivers Experiences.

Guidelines recommend advance care planning (ACP) for people with advanced illness; however, evidence supporting ACP as a component of outpatient care is lacking. We sought to establish the feasibility and acceptability of a facilitated ACP intervention for people attending tertiary outpatient clinics. Data from 20 semi-structured interviews with patient (M = 79.3 ± 7.7, 60% male) and caregiver (M = 68.1 ± 11.0, 60% female) participants recruited as part of a pragmatic, randomized controlled trial (RCT) were analyzed using qualitative descriptive methodology. Patients were randomized to intervention (e.g., facilitated support) or control (e.g., standard care). Intervention patients expressed high satisfaction, reporting the facilitated ACP session was clear, straightforward, and suited to their needs. Intervention caregivers did not report any significant concerns with the facilitated ACP process. Control participants reported greater difficulty completing ACP compared to intervention participants. Embedding facilitated ACP into tertiary outpatient care appears feasible and acceptable for people with advanced illnesses.

Feasibility and acceptability of facilitated advance care planning in outpatient clinics: A qualitative study of health-care professionals experience.

OBJECTIVE: This study sought to determine the feasibility and acceptability of a facilitated advance care planning (ACP) intervention implemented in outpatient clinics, as perceived by health-care professionals (HCPs). METHODS: Data from seven focus groups (n = 27) and nine semi-structured interviews with HCPs recruited as part of a pragmatic, randomised controlled trial (RCT) were analysed using qualitative descriptive methodology. Components of the intervention included HCP education and training, tools to assist HCPs with patient selection, hardcopy information, and ACP documentation, and specialised nurse-facilitators to support HCPs to complete ACP conversations and documentation with patients and caregivers. RESULTS: Health-care professionals working in tertiary outpatient clinics perceived the facilitated ACP intervention as feasible and acceptable. Health-care professionals reported a high level of satisfaction with key elements of the intervention, including the specialised education and training, screening and assessment procedures and ongoing support from the nurse-facilitators. Health-care professionals reported this training and support increased their confidence and ACP knowledge, leading to more frequent ACP discussions with patients and their families. Health-care professionals noted their ability to conduct ACP screening and assessment in clinic was impeded by large clinical caseloads and patient-related factors (e.g., dementia diagnoses, and emotional distress). Additional barriers to ACP implementation identified by HCPs included poor collaboration, constrained time and clinical space, undefined roles and standardised recording procedures for HCPs. CONCLUSIONS: Facilitated ACP intervention in outpatient clinics is perceived by HCPs as feasible and acceptable. Addressing barriers and tailoring implementation strategies may improve the delivery of ACP as part of tertiary outpatient care.

Disease Focused Integrated Care - a New Model of Healthcare Delivery for the Treatment of Skin Cancer.

Introduction: As the most common cancer in Australia, skin cancer generates a considerable health burden. This study outlines the establishment of a new model of integrated care for the diagnosis and management of skin cancer. Methods: A new model of integrated care was established to provide access to all aspects of skin cancer management. General practitioners (GPs) were upskilled through hands-on training and a 6-month skin cancer education program and partnered with specialist Dermatologists and Plastic Surgeons co-located in the same clinic. Data including median wait times between the initial consultation and treatment were prospectively collected and compared patients seen through the integrated pathway to patients referred from their primary GP to specialist Dermatologists and Plastic Surgeons directly (non-integrated pathway). The percentage of patients needing co-consultation with a specialist in the integrated pathway was also measured over time. Results: A total of 25341 patients were seen from the commencement of the clinic in August 2015 to June 2021. In 2017 and 2018 the median wait time to be treated was 7 days for the integrated model compared to 54 days (2017) and 46 days (2018) for non-integrated care (p < 0.0001). The percentage of GPs requesting specialist co-consultations for assessment of skin cancer fell from 98% in 2015, to 5.6% in 2021. Histopathology shows that 66% of lesions excised by GPs in this model were malignant or pre-malignant. Conclusions: This study firstly shows a significant reduction in time to treatment in an integrated skin cancer model over traditional models of health. Secondly it demonstrates GP upskilling over time in the integrated program. Integrating GP and specialist medical practitioners in the treatment of skin cancer offers potential for more efficient, accessible, and affordable care. This cooperative, co-located model may provide a template for the integrating the management of other conditions.

Preventable presentations of older adults to emergency departments: General practitioners' perspectives.

OBJECTIVE: To describe general practitioners' (GP) perspectives of older patients presenting to the ED, reasons they would refer to the ED and how they utilise community services to help manage older adults. METHODS: A descriptive study conducted in the Sutherland Shire, Sydney. Case files were compiled using electronic medical records for 50 patients over 70 years old who presented to the ED of The Sutherland Hospital, a teaching hospital in Sydney. Surveys were provided to 10 GPs who each analysed five patients' presentations. Primary outcome was whether the GP would refer the patient to the ED. Secondary outcomes included reasons GPs referred to the ED, and their referral patterns of local community services. RESULTS: Of the 50 patients who presented to the ED, GPs would have referred 21 (42%) to the ED and managed 29 (58%) in the community. The most common reasons GPs would have referred to the ED was that they were 'too unwell', or needed 'urgent imaging or blood tests'. In 26 (52%) of the patients, GPs were aware of a local service that could help manage the patient and would have made that referral in 21 (42%) patients. Rapid Access Diagnosis and Intervention Unit and Geriatric Flying Squad are two of the local aged care services GPs would have referred to most commonly. CONCLUSION: GPs reported they would have been able to manage a significant proportion of older adults who presented to the ED in the community without referring to the ED. Severe and acute illness requiring urgent evaluation and intervention was the main reason GPs would refer to the ED.

Cochrane vertebroplasty review misrepresented evidence for vertebroplasty with early intervention in severely affected patients.

The Cochrane vertebroplasty review of April 2018 was replaced with an updated version in November 2018 to address complaints of errors in analysis. The updated version continues to misrepresent the evidence supporting early intervention with vertebroplasty for patients with uncontrolled, severe pain and fracture duration <6 weeks. The VAPOUR trial is the only blinded trial of vertebroplasty restricted to this patient group. It showed the benefit of vertebroplasty over placebo, particularly when the intervention occurred within 3 weeks of fracture. The Cochrane vertebroplasty review has ignored the positive outcomes in the VAPOUR trial. Open randomised trials of fractures <6-week duration support the positive findings of the VAPOUR trial. This is not described in the Cochrane review. The VAPOUR trial is clinically heterogeneous from other blinded trials. Cochrane protocol stipulates that clinically heterogeneous trials be described separately, as independent evidence, and not combined in analysis with dissimilar trials. Failure to observe this represents a serious protocol breach in the Cochrane review.

Advance care planning for patients with advanced illnesses attending hospital outpatient clinics study: a study protocol for a randomised controlled trial.

INTRODUCTION: It is unclear whether advance care planning (ACP) undertaken with patients living in the community can improve patient care and avoid unwanted interventions and hospital admissions. We have designed a randomised controlled trial (RCT) to examine if ACP undertaken with patients with advanced illnesses attending hospital outpatient clinics can reduce unplanned hospital admissions and improve patient and caregiver well-being. METHODS AND ANALYSIS: Pragmatic RCT involving patients from subspecialty outpatient clinics at five clinical sites in Sydney, Australia. Participants will be ≥18 years screened as potentially having palliative care needs and at risk of dying in 6-12 months. The patients will be randomised to intervention or control group. Intervention group will undertake ACP discussions facilitated by a trained health professional. The control group will receive written information on ACP, representing the current standard of care. The primary outcome is the number of unplanned hospital admissions at the 6-month follow-up. Secondary outcomes include: (i) patient's health-related quality-of-life and quality of chronic disease care; (ii) caregiver's health-related quality-of-life and caregiver burden and (iii) other health outcomes including ambulance usage, emergency department presentations, hospital admissions, resuscitation attempts, intensive care unit admissions, deaths, documentation of patient wishes in patient records and audit of ACP discussions and documents. The staff's self-reported attitudes and knowledge of ACP will also be measured. The data will be collected using self-report questionnaires, hospital records audit, audit of ACP documentation and data linkage analysis. Semistructured interviews and focus group discussions with patients, caregivers and healthcare professionals will explore the acceptability and feasibility of the intervention. ETHICS AND DISSEMINATION: Approved by South-East Sydney Local Health District Human Research Ethics Committee and NSW Population and Health Services Research Ethics Committee. Results will be disseminated via conference presentations, journal publications, seminars and invited talks. TRIAL REGISTRATION NUMBER: ACTRN12617000280303.

Non-Genetic Risk Factors for Degenerative and Vascular Young Onset Dementia: Results from the INSPIRED and KGOW Studies.

BACKGROUND: Several brain reserve, vascular risk, and other modifiable factors have been associated with late-onset dementia, but their association with young onset dementia (YOD) has not been adequately explored. OBJECTIVE: To examine the association of cognitive reserve enhancing factors, cardiovascular risk factors (including smoking), depression, alcohol use, and traumatic brain injury (TBI) with non-autosomal dominant degenerative and/or vascular YOD. METHODS: Data for this matched case-control study were taken from two larger studies conducted in NSW, Australia. One comprised all people with YOD within a geographical region, while the other exclusively included Aboriginal and Torres Strait Islander participants. Dementia diagnosis was confirmed by clinical consensus, and risk exposure was retrospectively self- and/or informant-reported. RESULTS: Participants were 96 people with YOD (58.4% with probable Alzheimer's disease) and 175 age-group, sex, and sample matched control participants. Poor educational attainment, low participation in cognitive leisure activity, stroke, transient ischemic attack, and self-reported very heavy alcohol use were related to the risk of primary degenerative and/or vascular YOD. The effect of hypertension and depression varied depending on when they occurred relative to dementia onset. Current smoking was significantly associated with risk in univariate analyses but did not retain significance in multivariate modelling. There was no association with hypercholesterolemia, diabetes, or TBI of any kind. Some compensation for low educational attainment was possible via a complex occupation later in life. CONCLUSION: Non-genetic factors have a role in YOD, though the relative importance of each factor may be different to late onset dementia. The timing and severity of exposure, as well as the potential for compensation with later protective exposures, are important considerations for potential prevention strategies.