New horizons in the diagnosis and management of Alzheimer's Disease in older adults.

Alzheimer's Disease (ad) is the most common cause of dementia, and in addition to cognitive decline, it directly contributes to physical frailty, falls, incontinence, institutionalisation and polypharmacy in older adults. Increasing availability of clinically validated biomarkers including cerebrospinal fluid and positron emission tomography to assess both amyloid and tau pathology has led to a reconceptualisation of ad as a clinical-biological diagnosis, rather than one based purely on clinical phenotype. However, co-pathology is frequent in older adults which influence the accuracy of biomarker interpretation. Importantly, some older adults with positive amyloid or tau pathological biomarkers may never experience cognitive impairment or dementia. These strides towards achieving an accurate clinical-biological diagnosis are occurring alongside recent positive phase 3 trial results reporting statistically significant effects of anti-amyloid Disease-Modifying Therapies (DMTs) on disease severity in early ad. However, the real-world clinical benefit of these DMTs is not clear and concerns remain regarding how trial results will translate to real-world clinical populations, potential adverse effects (including amyloid-related imaging abnormalities), which can be severe and healthcare systems readiness to afford and deliver potential DMTs to appropriate populations. Here, we review recent advances in both clinical-biological diagnostic classification and future treatment in older adults living with ad. Advocating for access to both more accurate clinical-biological diagnosis and potential DMTs must be done so in a holistic and gerontologically attuned fashion, with geriatricians advocating for enhanced multi-component and multi-disciplinary care for all older adults with ad. This includes those across the ad severity spectrum including older adults potentially ineligible for emerging DMTs.

Virtual wards for people with frailty: what works, for whom, how and why-a rapid realist review.

BACKGROUND: Virtual wards (VWs) deliver multidisciplinary care at home to people with frailty who are at high risk of a crisis or in crisis, aiming to mitigate the risk of acute hospital admission. Different VW models exist, and evidence of effectiveness is inconsistent. AIM: We conducted a rapid realist review to identify different VW models and to develop explanations for how and why VWs could deliver effective frailty management. METHODS: We searched published and grey literature to identify evidence on multidisciplinary VWs. Information on how and why VWs might 'work' was extracted and synthesised into context-mechanism-outcome configurations with input from clinicians and patient/public contributors. RESULTS: We included 17 peer-reviewed and 11 grey literature documents. VWs could be short-term and acute (1-21 days), or longer-term and preventative (typically 3-7 months). Effective VW operation requires common standards agreements, information sharing processes, an appropriate multidisciplinary team that plans patient care remotely, and good co-ordination. VWs may enable delivery of frailty interventions through appropriate selection of patients, comprehensive assessment including medication review, integrated case management and proactive care. Important components for patients and caregivers are good communication with the VW, their experience of care at home, and feeling involved, safe and empowered to manage their condition. CONCLUSIONS: Insights gained from this review could inform implementation or evaluation of VWs for frailty. A combination of acute and longer-term VWs may be needed within a whole system approach. Proactive care is recommended to avoid frailty-related crises.

Exercise snacking to improve physical function in pre-frail older adult memory clinic patients: a 28-day pilot study.

BACKGROUND: Finding innovative yet feasible ways of preventing physical and cognitive decline in those at risk is a critical global challenge, with exercise being championed as a key precursor to robust health in later life. Exercise snacking, here defined as short bouts of sporadic [muscle-strengthening] exercise, is one such strategy designed to overcome typical participation barriers observed in older adults. This study examined the acceptability of exercise snacking amongst pre-frail older adults and explored the efficacy of this approach in improving physical function. METHODS: In this single group design, 21 pre-frail outpatients with mild-cognitive impairment were recruited from a UK memory clinic. To be eligible, participants were aged ≥ 65-years who scored 3-8 (inclusive) on the short physical performance battery (SPPB) and were not regularly engaging in sport or exercise. Participants completed a 28-day, twice daily, exercise snacking intervention, consisting of five muscle-strengthening exercises, with the aim being to complete as many repetitions as possible of each exercise in a minute. Acceptability of the intervention was measured quantitatively and qualitatively using a survey and topic guide informed by the Theoretical Framework of Acceptability. Pre- and post-intervention physical function was measured using the SPPB, timed up-and-go (TUG), and 60s standing balance and sit-to-stand tests. RESULTS: Eighteen participants provided follow-up data and showed 85% adherence to the exercise snacking intervention, measured as the proportion of all sessions completed out of a possible 56. Participants rated the intervention as highly acceptable (4.6/5) suggesting it supported their self-efficacy (4.3/5) was enjoyable (4.1/5) and had a low burden (2.1/5). Qualitative findings suggested the ease of use, flexibility of the programme, and perceived effectiveness was important, and particularly useful for non-exercisers. Changes in SPPB score (8(1) vs. 9(3), p < 0.01), TUG (11.32(4.02) vs. 9.18(5.25) seconds, p < 0.01) and in the 60-second sit-to-stand test (17 ± 5 vs. 23 ± 7 repetitions, p < 0.01) were seen between baseline and follow-up. CONCLUSIONS: Exercise snacking is an acceptable and potentially efficacious format of exercise for pre-frail memory clinic attendees who are at heightened risk of falling and frailty. Large scale randomised controlled trials are required to confirm whether exercise snacking is effective in the short and long term. GOV REGISTRATION: NCT05439252 (30/06/2022).

"A disembodied voice over the telephone": a qualitative study of healthcare practitioners' experiences in geriatric medicine.

OBJECTIVES: This study explored the experience of delivering care remotely among practitioners in a UK geriatric medicine clinic. METHODS: Nine semi-structured interviews were conducted with consultants (n = 5), nurses (n = 2), a speech and language and an occupational therapist, and thematically analysed. RESULTS: Four themes developed; Challenges of remote consultations; Perceived advantages of remote consultations; Disruption of involvement of family members; Impact on care staff. Participants felt that rapport and trust had been more feasible to develop remotely than they had anticipated, although this was more challenging for new patients and those with cognitive or sensory impairments. While practitioners identified advantages of remote consultations, including involving relatives, saving time, and reducing anxiety, they also experienced disadvantages such as consultations feeling like a 'production line', missing visual cues and reduced privacy. Some participants felt their professional identity was threatened by the lack of face-to-face contact, linked to feeling that remote consultations are not suitable for frail older adults or those with cognitive deficits. DISCUSSION: Staff perceived barriers to remote consultations that went beyond practical concerns, and suggest support for building rapport, involving families, and protecting clinician identity and job satisfaction may be warranted.

Prescribing of direct oral anticoagulants and warfarin to older people with atrial fibrillation in UK general practice: a cohort study.

BACKGROUND: Anticoagulation for stroke prevention in atrial fibrillation (AF) has, historically, been under-used in older people. The aim of this study was to investigate prescribing of oral anticoagulants (OACs) for people aged ≥ 75 years in the UK before and after direct oral anticoagulants (DOACs) became available. METHODS: A cohort of patients aged ≥ 75 years with a diagnosis of AF was derived from the Clinical Practice Research Datalink (CPRD) between January 1, 2003, and December 27, 2017. Patients were grouped as no OAC, incident OAC (OAC newly prescribed) or prevalent OAC (entered study on OAC). Incidence and point prevalence of OAC prescribing were calculated yearly. The risk of being prescribed an OAC if a co-morbidity was present was calculated; the risk difference (RD) was reported. Kaplan-Meier curves were used to explore persistence with anticoagulation. A Cox regression was used to model persistence with warfarin and DOACs over time. RESULTS: The cohort comprised 165,596 patients (66,859 no OAC; 47,916 incident OAC; 50,821 prevalent OAC). Incidence of OAC prescribing increased from 111 per 1000 person-years in 2003 to 587 per 1000 person-years in 2017. Older patients (≥ 90 years) were 40% less likely to receive an OAC (RD -0.40, 95% CI -0.41 to -0.39) than younger individuals (75-84 years). The likelihood of being prescribed an OAC was lower with a history of dementia (RD -0.34, 95% CI -0.35 to -0.33), falls (RD -0.17, 95% CI -0.18 to -0.16), major bleeds (RD -0.17, 95% CI -0.19 to -0.15) and fractures (RD -0.13, 95% CI -0.14 to -0.12). Persistence with warfarin was higher than DOACs in the first year (0-1 year: HR 1.25, 95% CI 1.17-1.33), but this trend reversed by the third year of therapy (HR 0.75, 95% CI 0.63-0.89). CONCLUSIONS: OAC prescribing for older people with AF has increased; however, substantial disparities persist with age and co-morbidities. Whilst OACs should not be withheld solely due to the risk of falls, these results do not reflect this national guidance. Furthermore, the under-prescribing of OACs for patients with dementia or advancing age may be due to decisions around risk-benefit management. TRIAL REGISTRATION: EUPAS29923 . First registered on: 27/06/2019.

Estimating premorbid intelligence in people living with dementia: a systematic review.

OBJECTIVES: In diagnosing dementia, estimating premorbid functioning is critical for accurate detection of the presence and severity of cognitive decline. However, which assessments of premorbid intelligence are most suitable for use in clinical practice is not well established. Here, we systematically evaluate the validity of instruments for measuring premorbid intelligence in people living with dementia. DESIGN AND SETTING: In this systematic review, electronic databases (EMBASE, PsycINFO, MEDLINE, CINAHL, and AMED) were searched to identify studies reporting on objective measures of premorbid intelligence in dementia. Participants from included studies were recruited from local communities and clinical settings. PARTICIPANTS: A total of 1082 patients with dementia and 2587 healthy controls were included in the review. MEASUREMENTS: The literature search resulted in 13 eligible studies describing 19 different instruments. The majority of instruments (n = 14) consisted of language-based measures, with versions of the National Adult Reading Test (NART) being most commonly investigated. RESULTS: Preliminary evidence suggested comparable performance of patients with mild dementia and healthy controls on word reading tasks in English, Portuguese, Swedish, and Japanese. In moderate dementia, however, the performance was significantly impaired on most verbal tasks. There was a lack of reliability and validity testing of available instruments, with only one of the included studies reporting psychometric properties within the patient group. CONCLUSIONS: The results demonstrate that there is a wide range of tools available for estimating premorbid intelligence in dementia, with cautious support for the potential of word reading tasks across different languages in individuals with mild dementia. However, the review highlights the urgent need for extensive assessments of the psychometric properties of these tasks in dementia. We propose that further longitudinal research and assessments of nonverbal measures are necessary to validate these instruments and enhance diagnostic procedures for people living with dementia worldwide.

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.

Ambulatory blood pressure monitoring in older people with dementia: a systematic review of tolerability.

BACKGROUND: ambulatory blood pressure monitoring (ABPM) may be helpful for the management of hypertension, but little is known about its tolerability in people with dementia. OBJECTIVE: to review the published evidence to determine the tolerability of ABPM in people with dementia. METHODS: English language search conducted in MEDLINE and EMBASE, using 'Ambulatory blood pressure' AND 'Dementia' (and associated synonyms) from 1996 to March 2015. INCLUSION CRITERIA: people diagnosed with dementia AND in whom blood pressure was measured using ABPM. The initial search was undertaken using title and abstract reviews, with selected papers being agreed for inclusion by two reviewers. Potentially eligible papers were assessed, and high-quality papers were retained. Two reviewers agreed the abstracted data for analysis. Meta-analysis was used to combine results across studies. RESULTS: of the 221 screened abstracts, 13 studies (6%) met inclusion criteria, 5 had sufficient data and were of sufficient quality, involving 461 participants, most of whom had mild-moderate dementia. 77.7% (95% CI 62.2-93.2%) were able to tolerate ABPM; agreement with office BP was moderate to weak (two studies only-coefficients 0.3-0.38 for systolic blood pressure and 0.11-0.32 for diastolic blood pressure). One study compared home BP monitoring by a relative or ambulatory BP monitoring with office BP measures and found high agreement (κ 0.81). The little available evidence suggested increased levels of dementia being associated with reduced tolerability. CONCLUSIONS: ABPM is well tolerated in people with mild-moderate dementia and provides some additional information over and above office BP alone. However, few studies have addressed ABPM in people with more severe dementia.

New horizons: the management of hypertension in people with dementia.

The optimal management of hypertension in people with dementia is uncertain. This review explores if people with dementia experience greater adverse effects from antihypertensive medications, if cognitive function is protected or worsened by controlling blood pressure (BP) and if there are subgroups of people with dementia for whom antihypertensive therapy is more likely to be harmful. Robust evidence is scant, trials of antihypertensive medications have generally excluded those with dementia. Observational data show changes in risk association over the life course, with high BP being a risk factor for cognitive decline in mid-life, while low BP is predictive in later life. It is therefore possible that excessive BP lowering in older people with dementia might harm cognition. From the existing literature, there is no direct evidence of benefit or harm from treating hypertension in people with dementia. So what practical steps can the clinician take? Assess capacity, establish patient preferences when making treatment decisions, use ambulatory monitoring to thoroughly assess BP, individualise and consider deprescribing where side effects (e.g. hypotension) outweigh the benefits. Future research might include pragmatic randomised trials of targeted deprescribing, which include patient-centred outcome measures to help support decision-making and studies to address mechanistic uncertainties.

The treatment of hypertension in people with dementia: a systematic review of observational studies.

BACKGROUND: Hypertension is very common in older people and a number of trials of antihypertensives have demonstrated benefit from treatment in even the oldest old. However, people with dementia were significantly under-represented in these studies and as a population are more likely to be physically frail, to suffer orthostatic hypotension and to experience adverse effects from polypharmacy at a lower drug count. It may be that different thresholds for commencement and cessation of treatment should be considered and may already be used for this group. Against this background this review sets out to describe the prevalence of hypertension in people with dementia, its treatment, change in treatment over time and the achievement of blood pressure (BP) control. METHODS: The PubMed, Cochrane, Embase and PsychINFO databases were searched for observational studies involving people with dementia and a diagnosis of hypertension. The search was limited to English language articles involving adults and humans published from 1990 onwards. Abstracts and titles were then reviewed with eligible articles read in full. Bibliographies were examined for further relevant studies. The final selection of studies was then analysed and appraised. RESULTS: Thirteen articles were identified for analysis. The prevalence of hypertension in people with dementia was 45% (range 35%-84%). 73% of these were on at least one antihypertensive, with diuretics being the most common. The reported prevalence of hypertension in study populations remained unchanged over time. ACEi/ARBs and calcium channel blockers were prescribed more frequently in more recent studies whilst use of ß-blockers and diuretics remained unchanged. Target blood pressure was achieved in 55% of those on treatment. CONCLUSION: Hypertension is as common in people with dementia as in other populations and is as commonly treated with antihypertensive drugs. The findings presented here will support further work to establish the risk-benefit of antihypertensive treatment in patients with dementia and, if differing ratios are identified, to establish dementia-specific guidelines for management.

The Burden of Managing Medicines for Older People With Sensory Impairment: An Ethnographic-Informed Study.

Background: Older age is associated with increased prevalence of sensory impairment and use of medicines. Objectives: To explore the daily "medicine journey" of older people with sensory impairment. Methods: The study used ethnographic-informed methods (using audio-, photo- and video-recordings, diary notes and semi-structured interviews with researchers) and involved community-dwelling adults (aged > 65) in Scotland, with visual and/or hearing impairment and using >4 medicines. Data analysis used the constant comparative method. Results: Fourteen older people with sensory impairment participated and used a mean of 11.0 (SD 5.0) medicines (range 5-22). Participants reported difficulties with medicine ordering, obtaining, storage, administration and disposal. They used elaborate strategies to manage their medicines including bespoke storage systems, fixed routines, simple aids, communication, and assistive technologies. Conclusion: Older people with sensory impairment experience substantial burden, challenges and risk with medicines management. Tailored medicine regimens and assistive technologies could provide greater support to older people with sensory impairment.

A pragmatic cluster randomised controlled trial of air filtration to prevent symptomatic winter respiratory infections (including COVID-19) in care homes (AFRI-c) in England: Trial protocol.

BACKGROUND: Respiratory tract infections are readily transmitted in care homes. Airborne transmission of pathogens causing respiratory tract illness is largely unmitigated. Portable high-efficiency-particulate-air (HEPA) filtration units capture microbial particles from the air, but it is unclear whether this is sufficient to reduce infections in care home residents. The Air Filtration to prevent symptomatic winter Respiratory Infections (including COVID-19) in care homes (AFRI-c) randomized controlled trial will determine whether using HEPA filtration units reduces respiratory infection episodes in care home residents. METHODS: AFRI-c is a cluster randomized controlled trial that will be delivered in residential care homes for older people in England. Ninety-one care homes will be randomised to take part for one winter period. The intervention care homes will receive HEPA filtration units for use in communal areas and private bedrooms. Normal infection control measures will continue in all care homes. Anonymised daily data on symptoms will be collected for up to 30 residents. Ten to 12 of these residents will be invited to consent to a primary care medical notes review and (in intervention homes) to having an air filter switched on in their private room. The primary outcome will be number of symptomatic winter respiratory infection episodes. Secondary outcomes include specific clinical measures of infection, number of falls / near falls, number of laboratory confirmed infections, hospitalisations, staff sickness and cost-effectiveness. A mixed methods process evaluation will assess intervention acceptability and implementation. DISCUSSION: The results of AFRI-c will provide vital information about whether portable HEPA filtration units reduce symptomatic winter respiratory infections in older care home residents. Findings about effectiveness, fidelity, acceptability and cost-effectiveness will support stakeholders to determine the use of HEPA filtration units as part of infection control policies.

Anticoagulant use in older persons at risk for falls: therapeutic dilemmas-a clinical review.

PURPOSE: The aim of this clinical narrative review was to summarise the existing knowledge on the use of anticoagulants and potential adverse events in older people at risk of falls with a history of atrial fibrillation or venous thromboembolism. The review also offers practical steps prescribers can take when (de-)prescribing anticoagulants to maximise safety. METHODS: Literature searches were conducted using PubMed, Embase and Scopus. Additional articles were identified by searching reference lists. RESULTS: Anticoagulants are often underused in older people due to concerns about the risk of falls and intracranial haemorrhage. However, evidence suggests that the absolute risk is low and outweighed by the reduction in stroke risk. DOACs are now recommended first line for most patients due to their favourable safety profile. Off-label dose reduction of DOACs is not recommended due to reduced efficacy with limited reduction in bleeding risk. Medication review and falls prevention strategies should be implemented before prescribing anticoagulation. Deprescribing should be considered in severe frailty, limited life expectancy and increased bleeding risk (e.g., cerebral microbleeds). CONCLUSION: When considering whether to (de-)prescribe anticoagulants, it is important to consider the risks associated with stopping therapy in addition to potential adverse events. Shared decision-making with the patient and their carers is crucial as patient and prescriber views often differ.

Therapeutic dilemmas: cognitive enhancers and risk of falling in older adults-a clinical review.

PURPOSE: Cognitive enhancers are the primary pharmacological therapy prescribed to those with dementia, comprising of memantine and the acetylcholinesterase inhibitors (AChEIs). The long-term cognitive and behavioural benefits of these medications, as well as their potential contribution to falls is currently debated, with recent Delphi studies being unable to reach consensus on whether these medications should be deprescribed. In this narrative clinical review, as part of a series on deprescribing in people at risk of falls, we explore the potential falls-related side effects experienced in people taking cognitive enhancers, alongside situations where deprescribing may be appropriate. METHODS: We undertook a literature search of PubMed and Google Scholar, using terms capturing falls and cognitive enhancers, as well as consulting the British National Formulary and published Summary of Medicinal Product Characteristics. These searches informed the subsequent clinical review. RESULTS: Cognitive enhancers should be subject to regular review, including confirmation of appropriate treatment indication, and occurrence of side effects in the context of falls. AChEIs, in particular, are associated with a broad range of side effects that can contribute to increased falls risk. These include bradycardia, syncope and neuromuscular effects. Where these have been identified, deprescribing should be considered, as well as alternative treatment options. Deprescribing studies have shown mixed results, likely due to considerable methodological heterogeneity. Several suggested guidelines exist to aid deprescribing decisions, many of which are highlighted in this review. CONCLUSIONS: The use of cognitive enhancers should be regularly reviewed and decisions to deprescribe made on a case-by-case basis, considering both the risks and benefits of stopping these medications.