Drug-induced orthostatic hypotension: Cluster analysis of co-prescription patterns in older people in UK primary care.

PURPOSE: Over 250 medications are reported to cause orthostatic hypotension, associated with serious adverse outcomes in older adults. Studies suggest a harmful cumulative risk of orthostatic hypotension with multiple medication use. However, there is limited evidence on the potential for harm in practice, particularly which drugs is co-prescribed and may increase risk of orthostatic hypotension. METHODS: Retrospective cohort study and cluster analysis using general practice data from IQVIA Medical Research Data (IMRD) in patients aged ≥50 contributing data between 1 January 2018 and 31 December 2018. Thirteen drug groups known to be associated with orthostatic hypotension by mechanism, were analyzed and clusters generated by sex and age-band. RESULTS: A total of 602 713 individuals aged ≥50 with 283 912 (47%) men and 318 801 (53%) women were included. The most prevalent prescriptions that might contribute to orthostatic hypotension were ACE inhibitors, calcium-channel blockers, beta-blockers, selective serotonin reuptake inhibitors and uroselective alpha-blockers. We identified distinct clusters of cardiovascular system (cardiovascular system) drugs in men and women at all ages. cardiovascular system plus psychoactive drug clusters were common in women at all ages, and in men aged ≤70. cardiovascular system plus uroselective alpha-blockers were identified in men aged ≥70. CONCLUSIONS: Distinct clusters of drugs associated with orthostatic hypotension exist in practice, which change over the life course. Our findings highlight potentially harmful drug combinations that may cause cumulative risk of orthostatic hypotension in older people. This may guide clinicians about the potential of synergistic harm and to monitor for orthostatic hypotension if using combinations of cardiovascular system drugs, cardiovascular system plus psychoactive drugs and/or alpha-blockers-particularly in patients aged ≥70 or at high-risk due to comorbidity. Future research should consider quantifying the risk of drug-induced orthostatic hypotension with such drug combinations.

New horizons in the role of digital data in the healthcare of older people.

There are national and global moves to improve effective digital data design and application in healthcare. This New Horizons commentary describes the role of digital data in healthcare of the ageing population. We outline how health and social care professionals can engage in the proactive design of digital systems that appropriately serve people as they age, carers and the workforce that supports them. KEY POINTS: Healthcare improvements have resulted in increased population longevity and hence multimorbidity. Shared care records to improve communication and information continuity across care settings hold potential for older people. Data structure and coding are key considerations. A workforce with expertise in caring for older people with relevant knowledge and skills in digital healthcare is important.

Models of care and the role of clinical pharmacists in UK primary care for older adults: A scoping review protocol.

INTRODUCTION: There has been global investment of new ways of working to support workforce pressures, including investment in clinical pharmacists working in primary care by the NHS in the England. Clinical pharmacists are well suited to support older adults who have multiple long-term conditions and are on multiple medications. It is important to establish an evidence base for the role of clinical pharmacists in supporting older adults in primary care, to inform strategic and research priorities. The aim of this scoping review is to identify, map and describe existing research and policy/guidance on the role of clinical pharmacists in primary care supporting older adults, and the models of care they provide. METHODS AND ANALYSIS: A scoping review guided by the Joanne Briggs Institute methodology for scoping reviews, using a three-step strategy. We will search Medline, CINAHL, Scopus, EMBASE, Web of Science, PSYCHInfo, and Cochrane for English language articles, from 2015 -present day. Grey literature will be searched using Grey Matters guidelines, the Index of Grey Literature and Alternative Sources and Resources, and Google keyword searching. References of all included sources will be hand searched to identify further resources. Using the Population, Concept and Context framework for inclusion and exclusion criteria, articles will be independently screened by two reviewers. The inclusion and exclusion criteria will be refined after we become familiar with the search results, following the iterative nature of a scoping review. Data will be extracted using a data extraction tool using Microsoft Excel and presented using a narrative synthesis approach. ETHICS AND DISSEMINATION: Ethical approval is not required for this review. Review findings will be disseminated in academic conferences and used to inform subsequent qualitative research. Findings will be published and shared with relevant local and national organisations.

The association between frailty and anxiety: A systematic review.

OBJECTIVES: Previous systematic reviews show a clear relationship between frailty and depression, however the association with anxiety is much less frequently explored. Previous single studies indicate evidence is mixed. We completed a systematic review and meta-analysis to identify the relationship between frailty and anxiety. METHODS: We searched five electronic databases for observational studies in older people in community, care home and outpatient settings with any/no health conditions that measured the association between anxiety and frailty using validated measures. Studies were screened by one reviewer with 10% checked by a second reviewer. The Mixed Methods Appraisal Tool was used to assess study quality. We used meta-analysis to aggregate study findings, with subgroup analyses to explore heterogeneity. RESULTS: Out of 1272 references, a total of 20 cross-sectional and 1 longitudinal studies were eligible. Older adults with frailty were substantially more likely to display anxiety symptoms than robust populations, across both dichotomous and continuous data sets (n = 10, OR = 3.48, 95% CI: 2.08, 5.81, p < 0.0001, I2  = 94%; N = 5, SMD = 3.13, 95% CI: 1.06, 5.21, I2  = 98%). Similarly, pre-frail older adults were more likely to have anxiety symptoms than robust older adults but to a lesser extent (N = 6, OR = 1.95, 95% CI: 1.41, 2.71, I2  = 63%; N = 3, SMD = 1.70, 95% CI: 0.01, 3.38, I2  = 98%). CONCLUSIONS: There is a clear association between pre-frailty/frailty and anxiety in older adults. However, data are heterogeneous and primarily from cross-sectional studies so causality cannot be determined. Future research should evaluate the effectiveness of anxiety screening and treatments in frail older adults.

Polypharmacy and antidepressant acceptability in comorbid depression and type 2 diabetes: a cohort study using UK primary care data.

BACKGROUND: Polypharmacy may increase the risk of drug interactions, side effects, and poor adherence; however, the impact of polypharmacy on antidepressant acceptability in individuals with type 2 diabetes (T2DM) is unknown. AIM: To investigate the association between number of prescribed medications and early antidepressant discontinuation in adults with T2DM. DESIGN AND SETTING: Cohort study using UK primary care data from the Clinical Practice Research Datalink between 1 January 2000 and 31 December 2018. METHOD: Cox regression with penalised B-splines was used to describe the association between the number of concurrently prescribed medications at the time of starting antidepressant treatment and each of the outcomes. RESULTS: A total of 73 808 individuals with comorbid depression and T2DM starting antidepressant treatment for the first time were identified. A median of 7 concurrent medications were prescribed. Within 32 weeks, 44.26% (n = 32 665) of participants discontinued antidepressant treatment altogether, and 11.75% (n = 8672) of participants switched antidepressant agents. An inverse relationship between the number of concurrent medications and discontinuing antidepressant treatment altogether was found. The median of 7 concurrent medications was associated with a 65.06% decrease in early antidepressant discontinuation; hazard ratio 0.45, 95% confidence interval = 0.37 to 0.55. No evidence of an association between the number of concurrent medications and switching antidepressant agents was found. CONCLUSION: Early discontinuation of antidepressants is common in adults with T2DM; however, individuals with higher levels of concurrent polypharmacy may be more adherent to treatment. These are likely to represent individuals with worse physical or mental health. Individuals with lower levels of concurrent polypharmacy may benefit from adherence support.

Incidence of postural hypotension recorded in UK general practice: an electronic health records study.

BACKGROUND: Postural hypotension is a common condition associated with adverse outcomes in older adults. General practice plays an important role in identification of the condition. AIM: To examine the incidence of postural hypotension between 2008 and 2018 in general practice and how trends vary by age, sex, year, and social deprivation. DESIGN AND SETTING: Retrospective cohort study using electronic health records from the IQVIA Medical Research Data (IMRD) between 2008 and 2018. METHOD: Patients were included if they were aged ≥50 years. Incident postural hypotension was identified as a new (first) recording of a postural hypotension code. Recording of incident postural hypotension was estimated per 10 000 person-years at risk (PYAR) according to age, sex, year, and social deprivation. Incident rate ratios were estimated by multivariable Poisson regression. RESULTS: Of 2 911 260 patients, 24 973 had an electronic record indicating a new diagnosis of postural hypotension between 2008 and 2018. This was equivalent to 17.9 cases per 10 000 PYAR in males (95% confidence interval [CI] = 17.6 to 18.2) and 16.2 cases per 10 000 PYAR in females (95% CI = 15.9 to 16.5). A significant age-sex interaction was identified. Recorded postural hypotension rate increased with age and social deprivation, and reduced between 2008 and 2018. The rate was higher in males compared with females, particularly in older age groups (>80 years). CONCLUSION: To the authors' knowledge, this is the first study to quantify incident recorded postural hypotension in general practice. The rate is lower than expected compared with studies in screened older populations. Potential barriers to identification include underreporting, underdetection owing to lack of time and/or poorly standardised methods of measurement, and poor coding. Future research should investigate current practice and approaches for increased detection such as education, practical methods of screening, and standardised measurement of postural blood pressure.

Association between polypharmacy and depression relapse in individuals with comorbid depression and type 2 diabetes: a UK electronic health record study.

BACKGROUND: Individuals with physical comorbidities and polypharmacy may be at higher risk of depression relapse, however, they are not included in the 'high risk of relapse' group for whom longer antidepressant treatment durations are recommended. AIMS: In individuals with comorbid depression and type 2 diabetes (T2DM), we aimed to investigate the association and interaction between depression relapse and (a) polypharmacy, (b) previous duration of antidepressant treatment. METHOD: This was a cohort study using primary care data from the UK Clinical Practice Research Datalink (CPRD) from years 2000 to 2018. We used Cox regression models with penalised B-splines to describe the association between restarting antidepressants and our two exposures. RESULTS: We identified 48 001 individuals with comorbid depression and T2DM, who started and discontinued antidepressant treatment during follow-up. Within 1 year of antidepressant discontinuation, 35% of participants restarted treatment indicating depression relapse. As polypharmacy increased, the rate of restarting antidepressants increased until a maximum of 18 concurrent medications, where individuals were more than twice as likely to restart antidepressants (hazard ratio (HR) = 2.15, 95% CI 1.32-3.51). As the duration of previous antidepressant treatment increased, the rate of restarting antidepressants increased - individuals with a previous duration of ≥25 months were more than twice as likely to restart antidepressants than those who previously discontinued in <7 months (HR = 2.36, 95% CI 2.25-2.48). We found no interaction between polypharmacy and previous antidepressant duration. CONCLUSIONS: Polypharmacy and longer durations of previous antidepressant treatment may be associated with depression relapse following the discontinuation of antidepressant treatment.

Orthostatic Hypotension and Antiparkinsonian Drugs: A Systematic Review and Meta-analysis.

BACKGROUND: Orthostatic hypotension (OH) is multifactorial in Parkinson's disease (PD). Antiparkinsonian medication can contribute to OH, leading to increased risk of falls, weakness and fatigue. METHODS: We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) of antiparkinsonian drugs associated with OH as an adverse effect, compared to placebo. We searched EMBASE, MEDLINE and Web of Science databases until November 2020. Analysis used fixed-effects models and the GRADE tool to rate quality of evidence. Meta-analysis was performed if 3 or more studies of a drug group were available. RESULTS: Twenty-one RCTs including 3783 patients were included comparing 6 PD drug groups to placebo (MAO-B inhibitors, dopamine agonists, levodopa, COMT inhibitors, levodopa and adenosine receptor antagonists). OH was recorded as an adverse event or measurement of vital signs, without further specification on how this was defined or operationalised. Meta-analysis was performed for MAO-B inhibitors and dopamine agonists, as there were 3 or more studies for these drug groups. In this analysis, compared with placebo, neither MAO-B inhibitors or dopamine agonists were associated with increased risk of OH, (OR 2.28 [95% CI:0.81-6.46]), (OR 1.39 [95% CI:0.97-1.98]). CONCLUSIONS: Most studies did not specifically report OH, or reporting of OH was limited, including how and when it was measured. Furthermore, studies specifically reporting OH included participants that were younger than typical PD populations without multimorbidity. Future trials should address this, for example,, by including individuals over the age of 75, to improve estimations of how antiparkinsonian medications affect risk of OH.

Drug-induced orthostatic hypotension: A systematic review and meta-analysis of randomised controlled trials.

BACKGROUND: Drug-induced orthostatic hypotension (OH) is common, and its resulting cerebral hypoperfusion is linked to adverse outcomes including falls, strokes, cognitive impairment, and increased mortality. The extent to which specific medications are associated with OH remains unclear. METHODS AND FINDINGS: We conducted a systematic review and meta-analysis to evaluate the extent to which specific drug groups are associated with OH. EMBASE, MEDLINE, and Web of Science databases were searched from inception through 23 November 2020. Placebo-controlled randomised controlled trials (RCTs) on any drug reporting on OH as an adverse effect in adults (≥18 years) were eligible. Three authors extracted data on the drug, OH, dose, participant characteristics, and study setting. The revised Cochrane risk-of-bias tool for randomised trials (RoB 2) was used to appraise evidence. Summary odds ratios (ORs) were estimated for OH using fixed effects Mantel-Haenszel statistics. We conducted subgroup analysis on validity of OH measurement, drug dose, risk of bias, age, and comorbidity. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool was used to summarise the certainty of evidence. Of 36,940 citations, 69 eligible RCTs were included in the meta-analysis comprising 27,079 participants. Compared with placebo, beta-blockers and tricyclic antidepressants were associated with increased odds of OH (OR 7.76 [95% CI 2.51, 24.03]; OR 6.30 [95% CI 2.86, 13.91]). Alpha-blockers, antipsychotics, and SGLT-2 inhibitors were associated with up to 2-fold increased odds of OH, compared to placebo. There was no statistically significant difference in odds of OH with vasodilators (CCBs, ACE inhibitors/ARBs, SSRIs), compared to placebo. Limitations of this study are as follows: data limited to placebo-controlled studies, (excluding head-to-head trials), many RCTs excluded older participants; therefore results may be amplified in older patients in the clinical setting. The study protocol is publicly available on PROSPERO (CRD42020168697). CONCLUSIONS: Medications prescribed for common conditions (including depression, diabetes, and lower urinary tract symptoms) were associated with significantly increased odds of OH. Drugs causing sympathetic inhibition were associated with significantly increased odds of OH, while most vasodilators were associated with small nonsignificant differences in odds of OH, compared to placebo. Drugs targeting multiple parts of the orthostatic blood pressure (BP) reflex pathway (e.g. sympathetic inhibition, vasodilation, cardio-inhibitory effects) may carry cumulative risk, suggesting that individuals with polypharmacy could benefit from postural BP monitoring.

Vaccination uptake amongst older adults from minority ethnic backgrounds: A systematic review.

BACKGROUND: Older adults from minority ethnic backgrounds are at increased risk of contracting COVID-19 and developing severe infection and have increased risk of mortality. Whilst an age-based vaccination approach prioritising older groups is being implemented worldwide, vaccine hesitancy is high amongst minority ethnic groups. METHODS AND FINDINGS: We conducted a systematic review and convergent synthesis to systematically examine perceptions of vaccinations amongst older adults from minority ethnic backgrounds. We included studies that reported on perceptions, beliefs, and attitudes towards vaccinations in older adults aged ≥65 years from a minority ethnic background. We excluded studies of vaccinations in investigation or development, studies focused on specific medical conditions, studies where ethnic background or age group was unidentifiable, systematic reviews, editorials, and conference abstracts. We searched MEDLINE, Embase, Virtual Health Library, Web of Science, Cochrane Library, medRxiv, and PROSPERO databases from inception to 15 July 2021. Risk of bias for studies was assessed using the Mixed Methods Appraisal Tool. The quality of evidence of collective outcomes was estimated using the Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) framework. A total of 28 eligible studies conducted between 1997 and 2020 were included in the final analysis (17 quantitative surveys, 8 focus group or interview studies, 2 mixed methods studies, and 1 case-control study). The majority were US studies in English or Spanish, except for 6 studies set in Hong Kong, 2 studies in Japan, 1 study in Brazil, and 1 multi-centre study (including China, Indonesia, Turkey, South Korea, Greece, UK, Brazil, and Nigeria). In total, 28,262 individuals with an estimated mean age of 69.8 years were included, 63.2% of whom were female. We summarised the common concepts and themes across studies and populations using a convergent synthesis analysis. Thirteen themes categorised as barriers or facilitators were identified and grouped into structural factors-healthcare provider and system related, patient related, and policy and operational-and were analysed by minority ethnic group. The main limitation of the study was the predominance of studies from the US and East Asia. CONCLUSIONS: In this systematic review, we found that factors influencing vaccination uptake involve healthcare provider and system, patient-related, and governance-level factors that are specific to the older ethnic minority community being served. The evidence included in this review is supported by high or moderate certainty and can be translated to practice and policy. A tailored, multi-level approach combining increased education, access, and culturally competent discussions with trusted healthcare professionals to address health beliefs can maximise the potential impact of widespread vaccination policies.

Physical health monitoring in dementia and associations with ethnicity: a descriptive study using electronic health records.

BACKGROUND: Good physical health monitoring can increase quality of life for people with dementia, but the monitoring may vary and ethnic inequalities may exist. AIM: To investigate UK primary care routine physical health monitoring for people with dementia by: (a) ethnic groups, and (b) comorbidity status. DESIGN & SETTING: A retrospective cohort study was undertaken using electronic primary care records in the UK. METHOD: Physical health monitoring was compared in people with dementia from white, black, and Asian ethnic groups and compared those with ≥1 comorbidity versus no comorbidity, from 1 April 2015 to 31 March 2016. Using the Dementia : Good Care Planning framework and expert consensus, good care was defined as receiving, within 1 year: a dementia review; a blood pressure (BP) check (at least one); a GP consultation (at least one); a weight and/or body mass index (BMI) recording (at least one); and an influenza vaccination. RESULTS: Of 20 821 people with dementia, 68% received a dementia review, 80% at least one BP recording, 97% at least one GP contact, 48% a weight and/or BMI recording, and 81% an influenza vaccination in 1 year. Compared with white people, black people were 23% less likely and Asian people 16% less likely to have weight recorded (adjusted incidence rate ratio [IRR] = 0.77, 95% confidence interval [CI] = 0.60 to 0.98/0.84, 0.71 to 1.00). People without comorbidities were less likely to have weight recorded (adjusted IRR = 0.74, 95% CI = 0.69 to 0.79) and BP monitored (adjusted IRR = 0.71, 95% CI = 0.68 to 0.75). CONCLUSION: Ethnic group was not associated with differences in physical health monitoring, other than weight monitoring. Comorbidity status was associated with weight and BP monitoring. Physical health monitoring in dementia, in particular nutrition, requires improvement.

Differences in Psychotropic Drug Prescribing Between Ethnic Groups of People with Dementia in the United Kingdom.

PURPOSE: To test hypotheses that minority ethnic people with dementia in the UK receive fewer anti-dementia drugs and more psychotropic and anticholinergic drugs associated with harms. PATIENTS AND METHODS: We analyzed UK primary care electronic health records from The Health Improvement Network (THIN) database (2014-2016), comparing psychotropic drug prescribing initiation and duration between people with dementia from White, Black, and Asian ethnic groups. We repeated analyses in people (aged 50+) without dementia, to explore whether any differences found reflected prescribing patterns in the general older population, or were specific to dementia. RESULTS: We included 53,718 people with and 1,648,889 people without dementia. Among people with dementia, compared to White ethnic groups, Asian people were less likely to be prescribed anti-dementia drugs when they were potentially indicated (adjusted prevalence rate ratio 0.86 (95% Confidence Interval 0.76-0.98)), and received them for on average 15 days/year less. Compared to White groups, Asian and Black individuals with dementia were no more likely to take an antipsychotic drug, but those that had were prescribed them for 17 and 27 days/year more, respectively (190.8 (179.6-199.1) and 200.7 (191.1-206.5) days). Black people were less likely to be prescribed anxiolytics/hypnotics (0.60 (0.44-0.8)), but the duration these drugs were prescribed was similar across ethnic groups. Asian people were more likely to be prescribed anticholinergic drugs (1.43 (1.19-1.73)), in analyses unadjusted for cardiovascular comorbidities. Among people without dementia, those in the Asian and Black ethnic groups were less likely to be prescribed psychotropic drugs, relative to people from White groups. CONCLUSION: Among people with dementia, Asian groups received less potentially beneficial symptomatic treatments, and Asian and Black groups were prescribed antipsychotic drugs for longer than White ethnic groups. Our findings may indicate care inequalities.

Supporting nutrition in frail older people: a qualitative study exploring views of primary care and community health professionals.

BACKGROUND: Malnutrition is associated with increased morbidity and mortality, and is very common in frail older people. However, little is known about how weight loss in frail older people can be managed in primary care. AIMS: To explore the views and practices of primary care and community professionals on the management of malnutrition in frail older people; identify components of potential primary care-based interventions for this group; and identify training and support required to deliver such interventions. DESIGN AND SETTING: Qualitative study in primary care and community settings. METHOD: Seven focus groups and an additional interview were conducted with general practice teams, frailty multidisciplinary teams (MDTs), and community dietitians in London and Hertfordshire, UK (n = 60 participants). Data were analysed using thematic analysis. RESULTS: Primary care and community health professionals perceived malnutrition as a multifaceted problem. There was an agreement that there is a gap in care provided for malnutrition in the community. However, there were conflicting views regarding professional accountability. Challenges commonly reported by primary care professionals included overwhelming workload and lack of training in nutrition. Community MDT professionals and dietitians thought that an intervention to tackle malnutrition would be best placed in primary care and suggested opportunistic screening interventions. Education was an essential part of any intervention, complemented by social, emotional, and/or practical support for frailer or socially isolated older people. CONCLUSIONS: Future interventions should include a multifaceted approach. Education tailored to the needs of older people, carers, and healthcare professionals is a necessary component of any intervention.

A Systematic Review of Older Adults' Attitudes Towards Depression and Its Treatment.

BACKGROUND AND OBJECTIVES: Late-life depression is a major societal concern, but older adults' attitudes toward its treatment remain complex. We aimed to explore older adults' views regarding depression and its treatment. RESEARCH DESIGN AND METHODS: We undertook a systematic review and thematic synthesis of qualitative studies that explored the views of older community-dwelling adults with depression (not actively engaged in treatment), about depression and its treatment. We searched 7 databases (inception-November 2018) and 2 reviewers independently quality-appraised studies using the CASP checklist. RESULTS: Out of 8,351 records, we included 11 studies for thematic synthesis. Depression was viewed as a normal reaction to life stressors and ageing. Consequently, older adults preferred self-management strategies (e.g., socializing, prayer) that aligned with their lived experiences and self-image. Professional interventions (e.g., antidepressants, psychological therapies) were sometimes considered necessary for more severe depression, but participants had mixed views. Willingness to try treatments was based on a balance of different judgments, including perceptions about potential harm and attitudes based on trust, familiarity, and past experiences. Societal and structural factors, including stigma, ethnicity, and ageism, also influenced treatment attitudes. DISCUSSION AND IMPLICATIONS: Supporting older adults to self-manage milder depressive symptoms may be more acceptable than professional interventions. Assisting older adults with accessing professional help for more severe symptoms might be better achieved by integrating access to help within familiar, convenient locations to reduce stigma and increase accessibility. Discussing treatment choices using narratives that engage with older adults' lived experiences of depression may lead to greater acceptability and engagement.

'I've never drunk very much water and I still don't, and I see no reason to do so': a qualitative study of the views of community-dwelling older people and carers on hydration in later life.

BACKGROUND: dehydration is associated with significant adverse outcomes in older people despite being largely preventable and treatable. Little research has focused on the views of community-dwelling older people on hydration, healthy drinking and the perceived importance of drinking well in later life. OBJECTIVES: to understand community-dwelling older people and informal carers' views on hydration in later life and how older people can be supported to drink well. METHODS: qualitative study using interviews and a focus group exploring hydration and nutrition in later life (24 older people at risk of malnutrition and dehydration, 9 informal carers) and thematic analysis. RESULTS: this article presents the findings on hydration alone. Four themes are presented: perceptions of healthy drinking, barriers to and facilitators of drinking in later life and supporting older people to drink well. The perceived importance of adequate hydration in later life was polarised. Concerns about urinary incontinence and knowledge gaps were significant barriers. Consideration of individual taste preference and functional capacity acted as facilitators. Distinct habitual drinking patterns with medications and meals exist within individuals. Many relied on thirst at other times or when fluid demands are greater (such as hot weather), a known unreliable prompt in later life. CONCLUSIONS: older people could be supported to drink well by building upon existing habitual drinking patterns. Primary care and public health should consider individual barriers, facilitators and tailored education. A multidisciplinary approach to promote hydration should be incorporated into care for older people with more complex needs.

Exploring the Views and Dietary Practices of Older People at Risk of Malnutrition and Their Carers: A Qualitative Study.

BACKGROUND: While malnutrition is an important cause of morbidity and mortality in older people, it is commonly under-recognised. We know little on the views of community-dwelling older people and their carers regarding the management of malnutrition. The aim of the study was: (a) to explore views and dietary practices of older people at risk of malnutrition and their carers; (b) to identify gaps in knowledge, barriers and facilitators to healthy eating in later life; (c) to explore potential interventions for malnutrition in primary care. METHODS: A qualitative study was performed using semi-structured interviews with participants recruited from four general practices and a carers' focus group in London. Community-dwelling people aged ≥75, identified as malnourished or at risk of malnutrition (n = 24), and informal carers of older people (n = 9) were interviewed. Data were analysed using thematic analysis. RESULTS: Older people at risk of malnutrition rarely recognise appetite or weight loss as a problem. Commonly held perceptions include that being thin is healthy and 'snacking' is unhealthy. Changes in household composition, physical or mental health conditions and cognitive impairment can lead to inadequate food intake. Most carers demonstrate an awareness of malnutrition, but also a lack of knowledge of what constitutes a nutritious diet. Although older people rarely seek any help, most would value advice from their GP/practice nurse, a dietitian or another trained professional. CONCLUSION: Older people at risk of malnutrition and their carers lack knowledge on nutritional requirements in later life but are receptive to intervention. Training for health professionals in delivering tailored dietary advice should be considered.

Facial swelling and dysphonia during labour: a case of Hamman's syndrome.

We present the case of a previously fit and well 30-year-old primiparous woman who developed Hamman's syndrome during the second stage of labour. This is an unusual and peculiar condition, characterised by spontaneous pneumomediastinum and subcutaneous emphysema. The rarity of the condition means it can easily be misdiagnosed. Its exact aetiology is unknown, but it is believed that extreme Valsalva manoeuvre during prolonged or difficult labours may contribute to its development. Chest X-ray is the first investigation of choice in this presentation, followed by CT scanning. Fortunately, it is usually a benign condition that can be managed conservatively and resolved quickly, with no long-term effects and low risk of recurrence in future pregnancies. We are pleased to say that this case does not differ in this respect. It is, however, important to rule other more serious pathologies that present in a similar way, for example, Boerhaave syndrome, pneumothorax or pulmonary embolism.

Management of depression and referral of older people to psychological therapies: a systematic review of qualitative studies.

BACKGROUND: Depressive symptoms are common in later life and increase both the risk of functional and cognitive decline and the use of healthcare services. Despite older people expressing preferences for talking therapies, they are less likely to be referred than younger adults, particularly when aged ≥80 years. AIM: To explore how healthcare professionals (HCPs) manage older people in relation to depression and referrals to psychological therapies. DESIGN AND SETTING: Systematic review and thematic synthesis of qualitative studies. METHOD: MEDLINE, Embase, PsycINFO, CINAHL, and the Social Sciences Citation Index (inception-March 2018) were searched for studies exploring HCPs' views regarding management of late-life depression across all settings. Studies of older people's views or depression management across all ages were excluded. RESULTS: In total, 27 studies, were included; these predominantly focused on the views of GPs and primary and community care nurses. Many HCPs felt that late-life depression was mainly attributable to social isolation and functional decline, but treatments appropriate for this were limited. Clinicians perceived depression to have associated stigma for older adults, which required time to negotiate. Limited time in consultations and the complexity of needs in later life meant physical health was often prioritised over mental health, particularly in people with frailty. Good management of late-life depression appeared to depend more on the skills and interest of individual GPs and nurses than on any structured approach. CONCLUSION: Mental ill health needs to be a more-prominent concern in the care of older adults, with greater provision of psychological services tailored to later life. This may facilitate future identification and management of depression.