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BACKGROUND: Chronic subdural haematoma (cSDH) is a common neurosurgical pathology affecting older patients with other health conditions. A significant proportion (up-to 90%) of referrals for surgery in neurosciences units (NSU) come from secondary care. However, the organisation of this care and the experience of patients repatriated to non-specialist centres are currently unclear. OBJECTIVES: This study aimed to clarify patient outcome in non-specialist centres following NSU discharge for cSDH surgery and to understand key system challenges. The study was set within a representative neurosurgical care system in the east of England. DESIGN AND METHODS: We performed a retrospective cohort analysis of patients referred for cSDH surgery. Alongside case record review, patient and staff experience were explored using surveys as well as an interactive c-design workshop. Challenges were identified from thematic analysis of survey responses and triangulated by focussed workshop discussions. RESULTS: Data on 381 patients referred for cSDH surgery from six centres was reviewed. One hundred and fifty-six (41%) patients were repatriated following surgery. Sixty-one (39%) of those repatriated suffered an inpatient complication (new infection, troponin rise or renal injury) following NSU discharge, with 58 requiring institutional discharge or new care. Surveys for staff (n = 42) and patients (n = 209) identified that resourcing, communication, and inter-hospital distance posed care challenges. This was corroborated through workshop discussions with stakeholders from two institutions. CONCLUSIONS: A significant amount of perioperative care for cSDH is delivered outside of specialist centres. Future improvement initiatives must recognise the system-wide nature of delivery and the challenges such an arrangement presents.
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Hematoma Subdural Crônico , Humanos , Hematoma Subdural Crônico/diagnóstico , Hematoma Subdural Crônico/cirurgia , Estudos Retrospectivos , Pacientes Internados , Comunicação , Inglaterra/epidemiologiaRESUMO
BACKGROUND: A retrospective cohort study was undertaken to examine the management of basal cell carcinoma (BCC) in older patients. OBJECTIVES: The aim was to identify subgroups where intervention could be minimised, based on frailty and trends in survival. METHODS: All patients aged 90 years and over with histologically confirmed BCC during 2017 and 2018 were included within the study (n = 319). RESULTS: Age was the most significant predictor of survival (HR=1.10 (95% CIs: 1.04-1.17); p=0.001). Maximum threshold analysis identified 93 years as the significant age cutpoint. Median survival was 40 months for ≤93 years and 28 months for >93 years (p=0.002). Patients with dementia had a worse survival than those without (median survival: 25 months versus 35 months, respectively; HR=1.92 (95% CIs: 1.18-3.13); p=0.009). There was a statistically significant difference in survival for patients who received treatment for their BCC (n=294) compared those observed (n=25) (median survival 34 months versus 21 months, respectively; HR= 0.54 (95% CIs: 0.34-0.85); p=0.007). All other comorbidities examined had no influence on survival. CONCLUSIONS: This study provides evidence in support of active treatment of BCC in individuals aged ≥90 years, seen in secondary care. Conservative options may be preferable in patients with dementia or those >93 years old.
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In this viewpoint, we present evidence of a marked increase in the use of assistive technology (AT) by older adults over the last 25 years. We also explain the way in which this use has expanded not only as an increase in terms of the total number of users but also by going beyond the typical scopes of use from its inception in 1999 to reach new categories of users. We outline our opinions on some of the key driving forces behind this expansion, such as population demographic changes, technological advances, and the promotion of AT as a means to enable older adults to achieve independent living. As well as our review of the evolution of AT over the past 25 years, we also discuss the future of AT research as a field and the need for harmonization of terminology in AT research. Finally, we outline how our experience in North Norfolk (notably the United Kingdom's most old age-dependent district) suggests that cocreation may be the key to not only successful research trials in the field of AT but also to the successful sustained adoption of AT beyond its original scope of use.
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Vida Independente , Tecnologia Assistiva , Humanos , Idoso , Reino Unido , Idoso de 80 Anos ou maisRESUMO
BACKGROUND: The complexity of older patients along with trends in poorer outcomes in the emergency department (ED) has prompted research into how EDs can adapt to meet the needs of an aging population. A separate Older People's Emergency Department (OPED) has been proposed to improve care at the front door. OBJECTIVE: Compare patient flow in a dedicated OPED at a University Hospital in Norfolk, United Kingdom, against that of the main ED. METHODS: We carried out a retrospective cohort study to compare older patients attending the ED in 2019 against those attending the newly formed OPED service in 2020. Multivariable logistic regression was performed to estimate adjusted odds ratios (emergency admissions, meeting England's 4-h national target, re-admissions, all-cause 30-day mortality, clinical frailty screening, and discharge to original place of residence). RESULTS: Clinical assessment in the OPED did not significantly lower the proportion of patients admitted to the hospital (adjusted odds ratio 0.84; 95% confidence interval 0.61-1.16). There were significant reductions in overall time spent in the department, time to initial clinician review, and time to frailty screening. Patients seen in the OPED were more likely to meet the national 4-h target and more likely to be discharged to their original place of residence. CONCLUSIONS: Assessment in the OPED was not associated with a significantly reduced likelihood of hospitalization. However, patients had a shorter wait for clinical assessment, with concomitant reduction in department length of stay.
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Fragilidade , Humanos , Idoso , Tempo de Internação , Estudos Retrospectivos , Hospitalização , Serviço Hospitalar de Emergência , Inglaterra/epidemiologiaRESUMO
BACKGROUND: Half of older people are prescribed unnecessary/inappropriate medications that are not routinely deprescribed in hospital hence there is a need for deprescribing trials. We aimed to develop a Core Outcome Set (COS) for deprescribing trials for older people under the care of a geriatrician during hospital admission. METHODS: We developed a list of potentially relevant outcomes from the literature. Using a two-round Delphi survey of stakeholder groups representing older people and carers, hospital clinicians, hospital managers, and ageing/deprescribing researchers, each outcome was scored according to Grading of Recommendations Assessment, Development and Evaluation, followed by two consensus workshops to finalise the COS. RESULTS: Two hundred people completed Round 1 and 114 completed Round 2. Representing all stakeholder groups, 10 people participated in workshop 1 and 10 in workshop 2. Six outcomes were identified as most important, feasible and acceptable to collect in a trial: number of prescribed medicines stopped; number of prescribed medicines with dosage reduced; quality of life; mortality; adverse drug events and number of hospital stays. Three other outcomes were identified as important, but currently too burdensome to collect: number of potentially inappropriate medicines prescribed; burden from medication routine; and medication-related admissions to hospital. CONCLUSIONS: A COS represents the minimum outcomes that should be collected and reported. Whilst uncommon practice for COS development, the value of considering outcome collection feasibility is demonstrated by the removal of three potential outcomes that, if included, may have compromised COS uptake due to challenges with collecting the data.
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Desprescrições , Geriatras , Humanos , Idoso , Qualidade de Vida , Hospitais , Avaliação de Resultados em Cuidados de Saúde , Técnica DelphiRESUMO
BACKGROUND: hospital deprescribing trials have demonstrated marginal increases in deprescribing activity that are not sustained beyond the trial period. The hospital deprescribing implementation framework (hDIF) links barriers and enablers of deprescribing in hospital with 44 potential intervention components. This study aimed to support geriatricians and pharmacists to select and characterise hDIF components according to affordability, practicability, effectiveness, acceptability, safety and equity (APEASE) to design a deprescribing intervention in the English hospital setting. METHODS: we convened a modified Nominal Group Technique with a panel of nine geriatricians and pharmacists representing five English hospitals. Panel members selected and characterised intervention components from the hDIF based on the APEASE criteria. We set a consensus threshold of 80% agreement per APEASE criterion in order for the intervention component to be included. RESULTS: the panel selected five intervention components supporting engagement with deprescribing: an organisational action plan to prioritise deprescribing, two training activities to address pharmacists' beliefs about negative deprescribing consequences, restructuring pharmacists' working patterns to facilitate their contribution to deprescribing decisions, and sharing experiences of successfully engaging patients/family in deprescribing conversations to support others to do the same. A sixth component was selected to sustain engagement with deprescribing through measuring and sharing deprescribing activity achieved between teams. CONCLUSIONS: deprescribing interventions targeting geriatricians' and pharmacists' behaviour in the English hospital context should include the six characterised components. A component to sustain deprescribing activity is a notable omission from previously reported deprescribing interventions and may explain their failure to maintain efficacy beyond the short-term trial period.
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Desprescrições , Comunicação , Geriatras , Hospitais , Humanos , FarmacêuticosRESUMO
An 82-year-old female was admitted with chest pain and non-specific T wave changes on her ECG. After 72 hours of conservative management she deteriorated with non-specific symptoms including nausea and a single episode of vomiting. Abdominal and Chest X-rays were unremarkable, blood tests showed worsening Acute Kidney Injury (AKI) on Chronic Kidney Disease (CKD); and raised C-Reactive Protein (CRP) with no obvious symptoms or focus of infection. She rapidly deteriorated going into asystole cardiac arrest and attempts at resuscitation failed. Post-mortem examination suggested the most likely cause of death was acute spontaneous Haemopericardium due to Rivaroxaban therapy which she was on for non-valvular Atrial Fibrillation (AF). We believe that this might be the first reported mortality with Rivaroxaban-associated spontaneous haemopericardium in the UK.
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Fibrilação Atrial/tratamento farmacológico , Derrame Pericárdico/induzido quimicamente , Rivaroxabana/efeitos adversos , Idoso de 80 Anos ou mais , Fibrilação Atrial/complicações , Eletrocardiografia , Inibidores do Fator Xa/efeitos adversos , Evolução Fatal , Feminino , Humanos , Derrame Pericárdico/diagnóstico , Radiografia Torácica , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controleRESUMO
BACKGROUND: over 50% of older people in hospital are prescribed a pre-admission medicine that is potentially inappropriate; however, deprescribing by geriatricians and pharmacists is limited. This study aimed to characterise geriatricians' and pharmacists' barriers and enablers to deprescribing in hospital. It also intended to develop a framework of intervention components to facilitate implementation of hospital deprescribing. METHODS: fifty-four geriatricians and pharmacists representing four UK hospitals attended eight focus groups. We designed a topic guide to invite discussions about barriers and enablers to deprescribing. After thematic analysis, themes were mapped to the theoretical domains framework (TDF), enabling prioritisation of domains for behaviour change. We then identified evidence-based intervention components for changing behaviour within prioritised TDF domains. RESULTS: geriatricians and pharmacists described several deprescribing enablers in the hospital setting including alignment with their role and generalist knowledge, and routine patient monitoring. Five prioritised TDF domains represent the key barriers and enabler: patient and caregiver attachment to medication (social influence); perceptions that deprescribing is riskier than continuing to prescribe (beliefs about consequences); pharmacists' working patterns limiting capacity to support deprescribing (environmental context and resources); deprescribing being a low hospital priority (goals) and incentives to deprescribe (reinforcement). Prioritised TDF domains aligned with 44 evidence-based intervention components to address the barriers and enabler to hospital deprescribing. CONCLUSION: the behavioural determinants and their associated intervention components provide a hospital deprescribing implementation framework (hDIF). Intervention components should be selected from the hDIF to provide a theory and evidence-based intervention tailored to hospital contexts.
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Desprescrições , Geriatras , Farmacêuticos , Idoso , Feminino , Grupos Focais , Hospitalização , Humanos , Prescrição Inadequada/prevenção & controle , Prescrição Inadequada/estatística & dados numéricos , Masculino , Desenvolvimento de ProgramasRESUMO
BACKGROUND: Deprescribing is a partnership between practitioners, patients and caregivers. External characteristics including age, comorbidities and polypharmacy are poor predictors of attitude towards deprescribing. This hospital-based study aimed to describe the desire of patients and caregivers to be involved in medicine decision-making, and identify attitudinal predictors of desire to try stopping a medicine. METHODS: Patients and caregivers recruited from seven Older People's Medicine wards across two UK hospitals completed the revised Patients'Attitudes Towards Deprescribing (rPATD) questionnaire. Patients prescribed polypharmacy and caregivers involved in medication decision-making of such patients were eligible. A target of 150 patients and caregivers provided a 95% confidence interval of ±11.0% or smaller around rPATD item agreement. Descriptive statistics characterised participants and rPATD responses. Responses to items regarding desire to be involved in medication decision-making and desire to try stopping a medicine were used to address the aims. Binary logistic regression provided the adjusted odds ratios (OR) for predictors of desire to try stopping a medicine. RESULTS: Patient participants (N = 75) were a median (IQ) 87.0 (83.0, 90.0) years old and the median (IQ) number of pre-admission medication was 8.0 (6.0, 10.0). Caregiver participants (N = 76) were a median (IQ) 70.0 (57.0, 83.0) years old and the majority were a spouse (63.2%). For patients and caregivers respectively, the following were reported: 58.7 and 65.8% wanted to be involved in medication decision-making; 29.3 and 43.5% reported a desire to try stopping a medicine. Attitudinal predictors of low desire to try stopping a medicine for patients and caregivers are a perception that there are no unnecessary prescribed medicines [OR = 0.179 (patients) and 0.044 (caregivers)] and no desire for dose reduction [OR = 0.199 (patients) and 0.024 (caregivers)]. A perception of not being prescribed too many medicines also predicted low patient desire to try stopping a medicine [OR = 0.195]. CONCLUSION: A substantial proportion of patients and caregivers did not want to be involved medication decision-making, however this should not result in practitioners dismissing deprescribing opportunities. The three diagnostic indicators for establishing desire to try stopping a medicine are perceived necessity of the medicine, appropriateness of the number prescribed medications and a desire for dose reduction.
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Cuidadores/psicologia , Tomada de Decisões , Desprescrições , Serviços de Saúde para Idosos/tendências , Relações Médico-Paciente , Inquéritos e Questionários , Idoso , Idoso de 80 Anos ou mais , Tomada de Decisões/fisiologia , Feminino , Previsões , Conhecimentos, Atitudes e Prática em Saúde , Serviços de Saúde para Idosos/normas , Hospitais/normas , Hospitais/tendências , Humanos , Masculino , Pessoa de Meia-Idade , PolimedicaçãoRESUMO
The concluding statement of the Burns Commission, established to evaluate whether changes are needed to the Freedom of Information Act (FOIA), ruled no major legislative changes were required. As such Freedom of Information (FOI) legislation still enables anyone to obtain information from public authorities. In this brief report article we explore arguments regarding FOI as an instrument for healthcare research using an international research programme as a case study.
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Acesso à Informação/legislação & jurisprudência , Pesquisa Biomédica/legislação & jurisprudência , Confidencialidade , Análise Ética , Ética Médica , Disseminação de Informação/legislação & jurisprudência , Privacidade , Pesquisa Biomédica/ética , Coerção , Confidencialidade/ética , Confidencialidade/legislação & jurisprudência , Análise Custo-Benefício , Pesquisa sobre Serviços de Saúde/ética , Pesquisa sobre Serviços de Saúde/legislação & jurisprudência , Humanos , Privacidade/legislação & jurisprudência , Medicina Estatal , Reino UnidoRESUMO
OBJECTIVES: Global cognitive changes in older age affect driving behavior and road safety, but how spatial orientation differences affect driving behaviors is unknown on a population level, despite clear implications for driving policy and evaluation during aging. The present study aimed to establish how spatial navigation changes affect driving behavior and road safety within a large cohort of older adults. METHODS: Eight hundred and four participants (mean age: 71.05) were recruited for a prospective cohort study. Participants self-reported driving behavior followed by spatial orientation (allocentric and egocentric) testing and a broader online cognitive battery (visuomotor speed, processing speed, executive functioning, spatial working memory, episodic memory, visuospatial functioning). RESULTS: Spatial orientation performance significantly predicted driving difficulty and frequency. Experiencing more driving difficulty was associated with worse allocentric spatial orientation, processing speed, and source memory performance. Similarly, avoiding challenging driving situations was associated with worse spatial orientation and episodic memory. Allocentric spatial orientation was the only cognitive domain consistently affecting driving behavior in under 70 and over 70 age groups, a common age threshold for driving evaluation in older age. DISCUSSION: We established for the first time that worse spatial orientation performance predicted increased driving difficulty and avoidance of challenging situations within an older adult cohort. Deficits in spatial orientation emerge as a robust indicator of driving performance in older age, which should be considered in future aging driving assessments, as it has clear relevance for road safety within the aging population.
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Condução de Veículo , Envelhecimento Saudável , Humanos , Idoso , Orientação Espacial , Estudos Prospectivos , Cognição , Envelhecimento/psicologiaRESUMO
BACKGROUND: Trials of hospital deprescribing interventions have demonstrated limited changes in practitioner behaviour. Our previous research characterised four barriers and one enabler to geriatricians and pharmacists deprescribing in hospital that require addressing by a behaviour change intervention. Six behaviour change techniques (BCTs) have also been selected by the target audience using the hospital Deprescribing Implementation Framework (hDIF). This research aimed to co-design and operationalise the content, mode of delivery and duration/intensity of the six selected BCTs to develop the CompreHensive geriAtRician-led MEdication Review (CHARMER) deprescribing intervention. METHODS: We established co-design panels at three hospitals representing contextual factors likely to influence CHARMER implementation. Panels comprised geriatricians, pharmacists and other hospital staff likely to be involved in implementation. We convened two rounds of co-design workshops with each hospital to design a prototype for each BCT, which went for feedback at a final workshop attended by all three hospital panels. RESULTS: The six BCTs were co-designed into an intervention comprising:(1&2) Pharmacists' workshop with pros and cons of deprescribing activities, and videos of salient patient cases3 Regular geriatrician and pharmacist deprescribing briefings4 Videos of geriatricians navigating challenging deprescribing consultations5 Hospital deprescribing action plan6 Dashboard to benchmark deprescribing activitiesAutomated prompts to flag high-risk patients for deprescribing and a primary and secondary care deprescribing forum were proposed as additional BCTs by stakeholders. These were later excluded as they were not fidelitous to the theoretical determinants of geriatricians' and pharmacists' deprescribing behaviours. CONCLUSIONS: This study illustrates the integration of theory and co-design methodology with the target audience and staff likely to be involved in implementation of a hospital deprescribing behaviour change intervention. The development of an intervention that remains faithful to the underpinning mechanisms of action of behaviour change is a strength of this approach.
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Desprescrições , Geriatras , Humanos , Farmacêuticos , HospitaisRESUMO
INTRODUCTION: Over 50% of older adults are prescribed a medicine where the risk of harm outweighs the chances of benefit. During a hospital admission, older adults and carers expect medicines to be reviewed for appropriateness and any inappropriate medicines proactively deprescribed. While the principle of proactive deprescribing is an expectation of good prescribing practice, it is yet to become routine. The CompreHensive geriAtRician-led MEdication Review (CHARMER) study aims to develop and test a five-component behaviour change intervention to equip geriatricians and pharmacists to proactively deprescribe inappropriate medicines with older adults in hospital. This study aims to test the feasibility and acceptability of study processes and CHARMER implementation. METHODS AND ANALYSIS: A two-arm purposive allocation feasibility study is being undertaken at four acute hospitals in England, UK (three intervention and one control). The target sample is 400 patients across all hospitals. Primary outcome measures are: (1) participant recruitment rate and (2) participant attrition rate. Secondary outcome measures are: (1) hospital readmission rate; (2) mortality rate and (3) quality of life. Quantitative data will be checked for completeness and quality, and practitioner and patient demographics descriptively analysed. We will undertake a rapid qualitative analysis on observations, interviews and study meeting minutes data. A subsequent thematic analysis will be undertaken with codes mapped to the Theoretical Domains Framework and Normalisation Process Theory. Triangulation of qualitative and quantitative data will be undertaken. ETHICS AND DISSEMINATION: Ethics approval was obtained from Wales Research Ethics Committee 1 (IRAS ID 312494) and study approval from the Health Research Authority (22/WA/0087). Informed consent will be sought from all hospital staff involved in data collection activities and for patients involved in enhanced data collection activities. The findings of this study will be disseminated in peer-reviewed journals and conference presentations. TRIAL REGISTRATION: ISRCTN11899506.
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Desprescrições , Humanos , Idoso , Estudos de Viabilidade , Geriatras , Qualidade de Vida , Revisão de Medicamentos , HospitaisRESUMO
Spatial navigation impairments in Alzheimer's disease (AD) have been suggested to underlie patients experiencing spatial disorientation. Though many studies have highlighted navigation impairments for AD patients in virtual reality (VR) environments, the extent to which these impairments predict a patient's risk for spatial disorientation in the real world is still poorly understood. The aims of this study were to (a) investigate the spatial navigation abilities of AD patients in VR environments as well as in a real world community setting and (b) explore whether we could predict patients at a high risk for spatial disorientation in the community based on their VR navigation. Sixteen community-dwelling AD patients and 21 age/gender matched controls were assessed on their egocentric and allocentric navigation abilities in VR environments using the Virtual Supermarket Test (VST) and Sea Hero Quest (SHQ) as well as in the community using the Detour Navigation Test (DNT). When compared to controls, AD patients exhibited impairments on the VST, SHQ, and DNT. For patients, only SHQ wayfinding distance and wayfinding duration significantly predicted composite disorientation score on the DNT (ß = 0.422, p = 0.034, R2 = 0.299 and ß = 0.357, p = 0.046, R2 = 0.27 respectively). However, these same VR measures could not reliably predict which patients were at highest risk of spatial disorientation in the community (p > 0.1). Future studies should focus on developing VR-based tests which can predict AD patients at high risk of getting spatially disorientated in the real world.
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Doença de Alzheimer , Navegação Espacial , Realidade Virtual , Doença de Alzheimer/diagnóstico , Confusão , Humanos , Testes NeuropsicológicosRESUMO
BACKGROUND: Spatial disorientation is one of the earliest and most distressing symptoms seen in patients with Alzheimer disease (AD) and can lead to them getting lost in the community. Although it is a prevalent problem worldwide and is associated with various negative consequences, very little is known about the extent to which outdoor navigation patterns of patients with AD explain why spatial disorientation occurs for them even in familiar surroundings. OBJECTIVE: This study aims to understand the outdoor navigation patterns of patients with AD in different conditions (alone vs accompanied; disoriented vs not disoriented during the study) and investigate whether patients with AD experienced spatial disorientation when navigating through environments with a high outdoor landmark density and complex road network structure (road intersection density, intersection complexity, and orientation entropy). METHODS: We investigated the outdoor navigation patterns of community-dwelling patients with AD (n=15) and age-matched healthy controls (n=18) over a 2-week period using GPS tracking and trajectory mining analytical techniques. Here, for the patients, the occurrence of any spatial disorientation behavior during this tracking period was recorded. We also used a spatial buffer methodology to capture the outdoor landmark density and features of the road network in the environments that the participants visited during the tracking period. RESULTS: The patients with AD had outdoor navigation patterns similar to those of the controls when they were accompanied; however, when they were alone, they had significantly fewer outings per day (total outings: P<.001; day outings: P=.003; night outings: P<.001), lower time spent moving per outing (P=.001), lower total distance covered per outing (P=.009), lower walking distance per outing (P=.02), and lower mean distance from home per outing (P=.004). Our results did not identify any mobility risk factors for spatial disorientation. We also found that the environments visited by patients who experienced disorientation versus those who maintained their orientation during the tracking period did not significantly differ in outdoor landmark density (P=.60) or road network structure (road intersection density: P=.43; intersection complexity: P=.45; orientation entropy: P=.89). CONCLUSIONS: Our findings suggest that when alone, patients with AD restrict the spatial and temporal extent of their outdoor navigation in the community to successfully reduce their perceived risk of spatial disorientation. Implications of this work highlight the importance for future research to identify which of these individuals may be at an actual high risk for spatial disorientation as well as to explore the implementation of health care measures to help maintain a balance between patients' right to safety and autonomy when making outings alone in the community.
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One in four adults in the UK have two or more medical conditions. One in three adults admitted to hospital in the UK have five or more conditions. People with multimorbidity have poorer functional status, quality of life and health outcomes, and are higher users of ambulatory and inpatient care than those without multimorbidity. The entire healthcare system needs to change so that it can provide a better service for patients with multimorbidity. The system of healthcare professional education needs to change also. Clinical decision support has a clear role in the management of patients with multimorbidity. But, until now, clinical decision support tools have offered no support when dealing with patients with comorbidities; they have covered single conditions only. In light of this, BMJ Best Practice recently launched the Comorbidities Manager. This enables healthcare professionals to add a patient's comorbidities to an existing management plan and get a tailored plan instantly. This article outlines the importance of taking into account comorbidities when managing patients and the role that the BMJ Comorbidities Manager can play in this regard.
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OBJECTIVES: Assess feasibility of a cluster randomised controlled trial (RCT) to measure clinical and cost-effectiveness of an enhanced recovery pathway for people with hip fracture and cognitive impairment (CI). DESIGN: Feasibility trial undertaken between 2016 and 2018. SETTING: Eleven acute hospitals from three UK regions. PARTICIPANTS: 284 participants (208 female:69 male). INCLUSION CRITERIA: aged >60 years, confirmed proximal hip fracture requiring surgical fixation and CI; preoperative AMTS ≤8 in England or a 4AT score ≥1 in Scotland; minimum of 5 days on study ward; a 'suitable informant' able to provide proxy measures, recruited within 7 days of hip fracture surgery. EXCLUSION CRITERIA: no hip surgery; not expected to survive beyond 4 weeks; already enrolled in a clinical trial. INTERVENTION: PERFECT-ER, an enhanced recovery pathway with 15 quality targets supported by a checklist and manual, a service improvement lead a process lead and implemented using a plan-do-study-act model. PRIMARY AND SECONDARY OUTCOME MEASURES: Feasibility outcomes: recruitment and attrition, intervention acceptability, completion of participant reported outcome measures, preliminary estimates of potential effectiveness using mortality, EQ-5D-5L, economic and clinical outcome scores. RESULTS: 282 participants were consented and recruited (132, intervention) from a target of 400. Mean recruitment rates were the same in intervention and control sites, (range: 1.2 and 2.7 participants/month). Retention was 230 (86%) at 1 month and 54%(144) at 6 months. At 3 months a relatively small effect (one quarter of an SD) was observed on health-related quality of life of the patient measured with EQ-5D-5L proxy in the intervention group. CONCLUSION: This trial design was feasible with modifications to recruitment. Mechanisms for delivering consistency in the PERFECT-ER intervention and participant retention need to be addressed. However, an RCT may be a suboptimal research design to evaluate this intervention due to the complexity of caring for people with CI after hip fracture. TRIAL REGISTRATION NUMBER: ISRCTN99336264.
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Disfunção Cognitiva , Fraturas do Quadril , Análise Custo-Benefício , Estudos de Viabilidade , Feminino , Fraturas do Quadril/cirurgia , Hospitais , Humanos , Masculino , Qualidade de VidaRESUMO
Dementia-related missing incidents are a highly prevalent issue worldwide. Despite being associated with potentially life-threatening consequences, very little is still known about what environmental risk factors may potentially contribute to these missing incidents. The aim of this study was to conduct a retrospective, observational analysis using a large sample of police case records of missing individuals with dementia (n = 210). Due to the influence that road network structure has on our real world navigation, we aimed to explore the relationship between road intersection density, intersection complexity, and orientation entropy to the dementia-related missing incidents. For each missing incident location, the above three variables were computed at a 1 km radius buffer zone around these locations; these values were then compared to that of a set of random locations. The results showed that higher road intersection density, intersection complexity, and orientation entropy were all significantly associated with dementia-related missing incidents. Our results suggest that these properties of road network structure emerge as significant environmental risk factors for dementia-related missing incidents, informing future prospective studies as well as safeguarding guidelines.
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Demência/epidemiologia , Caminhada/estatística & dados numéricos , Comportamento Errante/estatística & dados numéricos , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Demência/psicologia , Feminino , Humanos , Incidência , Masculino , Polícia/estatística & dados numéricos , Qualidade de Vida , Características de Residência , Estudos Retrospectivos , Fatores de Risco , Caminhada/psicologia , Comportamento Errante/psicologiaRESUMO
BACKGROUND: Dementia-related missing incidents are highly prevalent but still poorly understood. This is particularly true for environmental/geospatial risk factors, which might contribute to these missing incidents. OBJECTIVE: The study aimed to conduct a retrospective, observational analysis on a large sample of missing dementia patient case records provided by the police (nâ=â210), covering dates from January 2014 to December 2017. In particular, we wanted to explore 1) whether there were any hotspot regions of missing incidents and 2) the relationship between outdoor landmark density and missing incidents. METHODS: Global spatial autocorrelation (Moran's I) was used to identify the potential hotspot regions for missing incidents. Meanwhile, spatial buffer and regression modelling were used to determine the relationship between outdoor landmark density and missing incidents. RESULTS: Our demographics measures replicated and extended previous studies of dementia-related missing incidents. Meanwhile, no hotspot regions for missing incidents were identified, while higher outdoor landmark density led to increased missing incidents. CONCLUSION: Our results highlight that missing incidents do not occur in isolated hotspots of regions but instead are endemic in patients regardless of location. Higher outdoor landmark density emerges as a significant geospatial factor for missing incidents in dementia, which crucially informs future safeguarding/intervention studies.
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Demência/epidemiologia , Meio Ambiente , Idoso , Idoso de 80 Anos ou mais , Demência/psicologia , Demografia , Feminino , Geografia , Humanos , Incidência , Masculino , Estudos Retrospectivos , Risco , Fatores de Risco , Navegação Espacial , Reino Unido/epidemiologiaRESUMO
Background Deprescribing medication may be in response to an adverse clinical trigger (reactive) or if future gains are unlikely to outweigh future harms (proactive). A hospital admission may present an opportunity for deprescribing, however current practice is poorly understood. Objective To quantify and describe the nature of deprescribing in a UK teaching hospital. Method Prescribing and discontinuation data for admission medication from a hospital's electronic prescribing system were extracted over 4 weeks. The rationale for discontinuation of a random sample of 200 was determined using medical records. This informed categorisation of deprescribing activity by clinicians into 'proactive' or 'reactive'. Data were extrapolated to estimate the proportion of admission medications deprescribed and the proportion which were reactive and proactive. Results From 24,552 admission medicines, 977 discontinuations were recorded. Of the 200 discontinuations sampled for review, only 44 (22.0%) were confirmed deprescribing activities; categorised into 7 (15.9%) proactive and 37 (84.1%) reactive. Extrapolation yielded 0.6% (95% CI 0.5-0.7%) of all admission medications deprescribed. Conclusion Limited deprescribing activity, dominated by reactive behaviour was identified, suggesting prescribers require a clinical trigger to prompt deprescribing. There may be scope for increasing proactive deprescribing in hospital, however the extent to which this is feasible is unknown.