Decisions on eating and drinking in older adults admitted with pneumonia and referred for swallowing difficulties.

PURPOSE: Older patients with pneumonia are commonly restricted from oral intake due to concerns towards aspiration. Eating and drinking with acknowledged risks (EDAR) is a shared decision-making process emphasising patient comfort. As part of our project to find the barriers and facilitators of EDAR, we aimed for this initial study to see how frequently EDAR was selected in practice. METHODS: We performed a retrospective cohort study at an acute hospital where EDAR was initially developed, of patients aged ≥ 75 years-old admitted with pneumonia and referred to speech and language therapy. RESULTS: Out of 216 patients, EDAR decisions were made in 14.4%. The EDAR group had a higher 1-year mortality than the modified/normal diet groups (p < 0.001). Pneumonia recurrence rate did not differ significantly between the groups (p = 0.070). CONCLUSION: EDAR decisions were comparatively less common and most were associated with end-of-life care. Underlying reasons for the low EDAR application rate must be investigated to maximise patient autonomy and comfort as intended by EDAR while minimising staff burden.

Referral patterns to Speech and Language Therapy in the UK before, during and after the Covid-19 Pandemic: dysphagia compared with communication disorders.

INTRODUCTION: Acquired swallowing impairment is a major public health issue that often leads to increased morbidity and slower recovery. Speech and Language Therapists (SLTs) have taken the lead in the assessment and treatment of dysphagia, which is reflected in guidelines where early intervention is recommended. This is in addition to the central role that SLTs play in the management of acquired communication impairments, since research indicates that patients with communication difficulties benefit from early and intensive therapy by SLTs. This increasing demand for SLTs is expected to cause conflicting pressures in their workload and therefore beneficial to consider workforce planning. The aim of this study was to examine real-world data in the UK to investigate this issue regarding changes in referral patterns of patients with dysphagia and/or communication disorders to SLTs over time, to assist with workforce planning. METHODS: We interrogated the Royal College of Speech and Language Therapists Online Outcome Tool, a national database, in this retrospective cohort study. We included patients evaluated between 2018 and 2022. We performed a subgroup analysis of patients aged ≥ 40 years who had a primary medical diagnosis of stroke. Data on age, primary diagnosis, time on caseload, primary Therapeutic Outcome Measure (TOM) scale and initial TOMs score on impairment were examined. RESULTS: From the database of 44,444 referrals to speech and language therapy, 5,254 referrals were included in the stroke and overall subgroup analyses. Referrals were 55.1% male, with a median age of 71 years. More than half (56.1%) of these referrals were for dysphagia. Referrals decreased during the COVID-19 pandemic but began to recover from 2021 onwards. The time on the SLT caseload has increased over the years from a median of 14 days (interquartile range (IQR) 0-56) in 2018 to 20 days (IQR 3-81) in 2022. While there were more referrals to SLT services for assessment and management of dysphagia than for communication in the overall population, in the stroke subgroup, referrals for communication disorders outnumbered referrals for dysphagia from 2020 onwards. Additionally, the severity of impairment on referral increased over the years. CONCLUSION: Real-world data indicates that referrals to SLT services are changing over time to include more complex and severely impaired patients, with a demand for both swallowing and communication disorders. These findings should inform staff allocation and remodeling of education/training for SLTs to better meet clinical and public health needs. The retrospective nature of this study limits the strength and generalisability of this data, and this topic warrants further investigation.

The Potential Role of Angiotensin-Converting Enzyme Inhibitors and Beta-Blockers in Reducing Pneumonia Severity in Older Adults.

Background Understanding the impact of pharmacological therapy on pneumonia severity is crucial for effective clinical management. The impact of angiotensin-converting enzyme inhibitors (ACEis) and beta-blockers (BBs) on pneumonia severity remains unknown, warranting further investigation. Methodology This retrospective study examined the hospital records of inpatients (≥75 years) admitted with community-acquired pneumonia in 2021. Pneumonia severity associated with the use of pre-established ACEi and BB therapy was documented using CURB-65 (confusion, uraemia, respiratory rate, blood pressure, age ≥65 years) and pneumonia severity index (PSI) scores. Descriptive statistics and multivariable linear regression were used to analyse differences across BB therapy, ACEi therapy, their combination, or neither (control group). Results A total of 803 patient records were examined, of whom 382 (47.6%) were male and 421 (52.4%) were female. Sample sizes for each group were as follows: control (n = 492), BB only (n = 185), ACEi only (n = 68), and BB + ACEi (n = 58). Distribution of aspiration pneumonia (AP) versus non-AP for each group, respectively, was control (21.1% vs. 78.9%), BB only (9.7% vs. 90.3%), ACEi only (7.3% vs. 92.7%), and ACEi + BB (12.1% vs. 87.9%). No significant differences in PSI and CURB-65 scores were found between intervention groups even after controlling for patient characteristics and irrespective of AP or non-AP aetiology. Patients with AP had significantly higher CURB-65 (p = 0.026) and PSI scores (p = 0.044) compared to those with non-AP. Conclusions Pre-prescribed ACEi or BB therapy did not appear to be associated with differences in pneumonia severity. There were no differences in pneumonia severity scores with ACEi and BB monotherapy or combined ACEi and BB therapy.

Prognostic factors of poor outcomes in pneumonia in older adults: aspiration or frailty?

PURPOSE: Little is known about the long-term and functional prognoses of older adults with pneumonia, which complicates their management. There is a common belief that aspiration is a poor prognostic factor; however, the diagnosis of aspiration pneumonia (AP) lacks consensus criteria and is mainly based on clinical characteristics typical of the frailty syndrome. Therefore, the poor prognosis of AP may also be a result of frailty rather than aspiration. This study investigated the impact of AP and other prognostic factors in older patients with pneumonia. METHODS: We performed a retrospective cohort study of patients aged 75 years and older, admitted with pneumonia in 2021. We divided patients according to their initial diagnosis (AP or non-AP), compared outcomes using Kaplan-Meier curves, and used logistic regression to identify independent prognostic factors. RESULTS: 803 patients were included, with a median age of 84 years and 52.7% were male. 17.3% were initially diagnosed with AP. Mortality was significantly higher in those diagnosed with AP than non-AP during admission (27.6% vs 19.0%, p = 0.024) and at 1 year (64.2% vs 53.1%, p = 0.018), with survival analysis showing a median survival time of 62 days and 274 days in AP and non-AP, respectively (χ2 = 9.2, p = 0.002). However, the initial diagnosis of AP was not an independent risk factor for poor prognosis in multivariable analysis. Old age, frailty and cardio-respiratory comorbidities were the main factors associated with death. CONCLUSION: The greater mortality in AP may be a result of increased frailty rather than the diagnosis of aspiration itself. This supports our proposal for a paradigm shift from making predictions based on the potentially futile labelling of AP or non-AP, to considering frailty and overall condition of the patient.

The predictive value of anticholinergic drug exposure and the outcome of pneumonia: a Danish database study.

INTRODUCTION: Older adults are susceptible to anticholinergic effects. Dysphagia and pneumonia are associated with anticholinergic usage, though a definitive causative relationship has not been established. There is no effective way to predict the prognosis of older adults with pneumonia; therefore, this study investigates the predictive value of anticholinergic burden. METHODS: Patients aged 65 years and above admitted for community-acquired pneumonia from 2011 to 2018 in Denmark were included through Danish registries. We calculated anticholinergic drug exposure using the CRIDECO Anticholinergic Load Scale (CALS). The primary outcome was in-hospital mortality, and other outcomes included intensive care unit admission, ventilator usage, length of stay, 30-day/90-day/1-year mortality, institutionalisation, home care utilisation and readmission. RESULTS: 186,735 patients were included in the in-hospital outcome analyses, 165,181 in the readmission analysis, 150,791 in the institutionalisation analysis, and 95,197 and 73,461 patients in the home care analysis at follow-up. Higher CALS score was associated with higher in-hospital mortality, with a mean risk increasing from 9.9% (CALS 0) to 16.4% (CALS >10), though the risk plateaued above a CALS score of 8. A higher CALS score was also associated with greater mortality after discharge, more home health care, more institutionalizations and higher readmission rates. CONCLUSIONS: High anticholinergic burden levels were associated with poor patient outcomes including short-/long-term mortality, dependence and readmission. It may be useful to calculate the CALS score on admission of older patients with pneumonia to predict their prognosis. This also highlights the importance of avoiding the use of drugs with a high anticholinergic burden in older patients.

Convergent and discriminant validity of the Minimal Eating Observation Form - version II: a cross-sectional study.

BACKGROUND: The Minimal Eating Observation Form - Version II (MEOF-II) is a brief and easy to use screening tool for eating difficulties, that is psychometrically robust. The aim of this study was to explore convergent (measuring similar constructs) and discriminant (measuring somewhat different constructs) validity of the MEOF-II to other validated dysphagia specific, activity and participation related instruments. METHODS: In this cross-sectional study, participants (n = 100, mean age 72, n = 42 women), diagnosed with either chronic pulmonary disease, Parkinson´s disease, Multiple Sclerosis, or stroke were recruited from rehabilitation centres. Patient-reported outcomes and clinical-rated assessments, capturing eating ability in general and swallowing in specific, included: The Dysphagia Handicap Index (DHI), the 4-question test (4QT), the Minimal Eating Observation Form - II, the Volume - Viscosity Swallow Test (V-VST), Flexible Endoscopic Evaluation of Swallowing (FEES) documented according to the Penetration-Aspiration Scale (PAS). Type of oral intake was documented using the Functional Oral Intake Scale (FOIS). Activities in daily living was assessed with Barthel index (BI). Spearman's correlation coefficient was used to analyze associations. The MEOF-II total score was hypothesised to have moderate correlations (r ≥ 0.3) with the other assessments, besides with PAS and FOIS (weak correlations, r < 0.3). RESULTS: In total 78 participants had any type of eating difficulties (MEOF-II), 69 reported dysphagia (4QT), 62 had dysphagia according to V-VST, 29 showed evidence of penetration/aspiration (PAS), and 31 participants had decreased oral intake ability (FOIS). The MEOF-II total score had moderate correlations with DHI, BI, 4QT, V-VST volume, and weak correlations with V-VST dysphagia and viscosity, PAS, and FOIS. Comparing a prior hypothesised correlation strengths against empirical findings showed that 83% of the hypothesised correlations were correct. CONCLUSIONS: The MEOF-II is a holistic and objective screening tool that can indicate the need for further assessment and corresponds well with the persons' subjective experiences. MEOF-II does not specifically assess the risk for penetration/aspiration.

Modified medication use in dysphagia: the effect of thickener on drug bioavailability-a systematic review.

INTRODUCTION: Dysphagia is associated with long-term conditions including strokes, dementia, Parkinson's disease and frailty. Dysphagia affects 30-40% of the population aged over 65 years-old. Adults with dysphagia often experience long-term conditions requiring multiple medications (often > 5) to manage these. The thickening of liquids is a common compensatory strategy in dysphagia management. Studies suggest that immersion in thickened liquids affects medicines' solubility in vitro. Clinicians and pharmacists are unaware of the pharmacokinetic/therapeutic effects of thickened liquids on oral medicines. We conducted a systematic review of existing literature on thickeners' effects on drug bioavailability. METHODOLOGY: We performed a literature search of MEDLINE & EMBASE. Search terms included: dysphagia/thickened diet (EMBASE only)/ bioavailability or absorption of medicines or pharmacokinetics; excluded: NG feeds/animal studies. STUDIES INCLUDED: all genders, countries, > 18 years, community and hospital settings. PRISMA guidance was followed. RESULTS: Five hundred seventy results were found, and 23 articles identified following the reference list review. Following an abstract and full-text review, 18 were included. Most articles evaluated thickeners on dissolution profiles in-vitro, with a few investigating in-vivo. Most studies were single-centre prospective studies identifying that thickeners generally affect dissolution rates of medications. Few studies assessed bioavailability or used clinical outcomes. CONCLUSION: Dysphagia and polypharmacy are common in older adults, but little is known about the effects of altering liquid viscosity on the therapeutic effect of most medications. Further larger-scale studies are required to evaluate the therapeutic impact of thickener, on a bigger range of medications, factoring in other variables such as type of thickener, viscosity of thickener and duration of immersion.

Are Bubbles the Future of Dysphagia Rehabilitation: A Systematic Review Analysing Evidence on the Use of Carbonated Liquids in Dysphagia Rehabilitation.

BACKGROUND: Dysphagia poses a huge health issue in our ageing population, impacting patients psychologically and through risk of aspiration, malnutrition and airway obstruction. The use of carbonated liquids to provide sensory enhancement as a tool to stimulate neuromuscular activity in dysphagia rehabilitation remains an area with limited research. This article reviews current evidence. METHOD: A data search of PubMed, CINAHL, EMBASE and Cochrane was undertaken with set search terms. Abstracts were reviewed and selected by two clinicians according to inclusion criteria and papers were assessed using PRISMA methodology. RESULTS: Selected publications (1992-2022) involved a median of 23 participants with predominantly neurogenic dysphagia. Despite the differences in study designs all used videofluroscopy (VF) to assess outcome measures except Morishita et al. who used fiberoptic endoscopic evaluation of swallow (FEES). The studies were small scale but showed encouraging results. However, there was heterogeneity between results of specific outcome measures. One study surveyed taste which was overall positively received. CONCLUSIONS: There continues to remain limited evidence to direct the use of carbonated liquids in rehabilitation of dysphagia, however its role shows some promise. The heterogeneity of not just study designs but also study participants seems to be a primary barrier. Whilst evidence is encouraging, further prospective studies standardising patient cohorts, methodologies and quantitative outcome measures must be carried out. Longitudinal studies to look at the role of carbonated liquids in secretion management is another area of potential interest. In conclusion the use of carbonated liquid in dysphagia rehabilitation may have a potential role but without firm evidence-based research, successful use in clinical practice cannot be implemented.

Development of Two Patient Self-Reported Measures on Functional Health Status (FOD) and Health-Related Quality of Life (QOD) in Adults with Oropharyngeal Dysphagia Using the Delphi Technique.

Introduction. Patient self-evaluation is an important aspect in the assessment of dysphagia and comprises both Functional Health Status (FHS) and Health-Related Quality of Life (HR-QoL). As many measures combine both FHS and HR-QoL, disease-related functioning cannot be distinguished from disease-related quality of life as experienced by the patient. Moreover, current patient self-reported measures are limited by poor and incomplete data on psychometric properties. Objective. This study aimed to establish content validity for the development of two new self-reported measures on FHS and HR-QoL in adults with oropharyngeal dysphagia (OD), in line with the psychometric taxonomy and guidelines from the COSMIN group (COnsensus-based Standards for the selection of health Measurement INstruments). Methods. Using the Delphi technique, international expert consensus was achieved; participants and patients with dysphagia evaluated relevance, comprehensiveness, and comprehensibility of definitions of relevant constructs (i.e., dysphagia, FHS and HR-QoL) and potential items. Results. A total of 66 Delphi participants from 45 countries achieved consensus across two rounds. The Delphi study resulted in two prototype measures, the Functional health status measure of Oropharyngeal Dysphagia (FOD) and the health-related Quality of life measure of Oropharyngeal Dysphagia (QOD), consisting of 37 and 25 items, respectively. Minimal revisions were required based on feedback by patients. Conclusions. This study provides evidence of good content validity for both newly developed prototype measures FOD and QOD. Future studies will continue the process of refining the measures, and evaluate the remaining psychometric properties using both Classic Test Theory (CTT) and Item Response Theory (IRT) models.

Pneumonia, Aspiration Pneumonia, or Frailty-Associated Pneumonia?

Pneumonia is a common reason for admission afflicting frail older adults. Those who are the frailest are more likely to be provided with a diagnosis of aspiration pneumonia. This diagnosis has no clear definition and no clinical consensus. It is therefore time to stop attempting to differentiate between pneumonia type and use the term frailty-associated pneumonia.

A Paradigm Shift in the Diagnosis of Aspiration Pneumonia in Older Adults.

In older adults, community-acquired pneumonia (CAP) is often aspiration-related. However, as aspiration pneumonia (AP) lacks clear diagnostic criteria, the reported prevalence and clinical management vary greatly. We investigated what clinical factors appeared to influence the diagnosis of AP and non-AP in a clinical setting and reconsidered a more clinically relevant approach. Medical records of patients aged ≥75 years admitted with CAP were reviewed retrospectively. A total of 803 patients (134 APs and 669 non-APs) were included. The AP group had significantly higher rates of frailty, had higher SARC-F scores, resided in institutions, had neurologic conditions, previous pneumonia diagnoses, known dysphagia, and were more likely to present with vomiting or coughing on food. Nil by mouth orders, speech therapist referrals, and broad-spectrum antibiotics were significantly more common, while computed tomography scans and blood cultures were rarely performed; alternative diagnoses, such as cancer and pulmonary embolism, were detected significantly less. AP is diagnosed more commonly in frail patients, while aspiration is the underlying aetiology in most types of pneumonia. A presumptive diagnosis of AP may deny patients necessary investigation and management. We suggest a paradigm shift in the way we approach older patients with CAP; rather than trying to differentiate AP and non-AP, it would be more clinically relevant to recognise all pneumonia as just pneumonia, and assess their swallowing functions, causative organisms, and investigate alternative diagnoses or underlying causes of dysphagia. This will enable appropriate clinical management.

The diagnosis of aspiration pneumonia in older persons: a systematic review.

PURPOSE: Community-acquired pneumonia (CAP) is highly common across the world. It is reported that over 90% of CAP in older adults may be due to aspiration. However, the diagnostic criteria for aspiration pneumonia (AP) have not been widely agreed. Is there a consensus on how to diagnose AP? What are the clinical features of patients being diagnosed with AP? We conducted a systematic review to answer these questions. METHODS: We performed a literature search in MEDLINE®, EMBASE, CINHAL, and Cochrane to review the steps taken toward diagnosing AP. Search terms for "aspiration pneumonia" and "aged" were used. Inclusion criteria were: original research, community-acquired AP, age ≥ 75 years old, acute hospital admission. RESULTS: A total of 10,716 reports were found. Following the removal of duplicates, 7601 were screened, 95 underwent full-text review, and 9 reports were included in the final analysis. Pneumonia was diagnosed using a combination of symptoms, inflammatory markers, and chest imaging findings in most studies. AP was defined as pneumonia with some relation to aspiration or dysphagia. Aspiration was inferred if there was witnessed or prior presumed aspiration, episodes of coughing on food or liquids, relevant underlying conditions, abnormalities on videofluoroscopy or water swallow test, and gravity-dependent distribution of shadows on chest imaging. Patients with AP were older, more frailer, and had more comorbidities than in non-AP. CONCLUSION: There is a broad consensus on the clinical criteria to diagnose AP. It is a presumptive diagnosis with regards to patients' general frailty rather than in relation to swallowing function itself.

Chin tuck against resistance exercise with feedback to improve swallowing, eating and drinking in frail older people admitted to hospital with pneumonia: protocol for a feasibility randomised controlled study.

BACKGROUND: Swallowing difficulties (dysphagia) and community-acquired pneumonia are common in frail older people and maybe addressed through targeted training of the anterior neck musculature that affects the swallow. We have developed a swallowing exercise rehabilitation intervention (CTAR-SwiFt) by adapting a previously established swallowing exercise to ensure patient safety and ease of execution in the frail elderly population. The CTAR-SwiFt intervention consists of a feedback-enabled exercise ball that can be squeezed under the chin, with real-time feedback provided via a mobile application. The aim of this study is to evaluate the feasibility of assessing the effectiveness of the CTAR-SwiFt intervention in reducing dysphagia and community-acquired pneumonia, prior to a larger-scale multi-centre randomised controlled trial. METHODS: We will recruit 60 medically stable patients over the age of 75 years who have been admitted with a diagnosis of pneumonia to the acute frailty wards at two participating hospitals in the UK. Study participants will be randomised into one of three groups: standard care, low intensity (once daily) CTAR-SwiFt exercise or high intensity (twice daily) CTAR-SwiFt exercises. The intervention period will last for 12 weeks, the final follow-up assessment will be conducted at 24 weeks. We will assess the feasibility outcomes, including rates of participant recruitment and retention, compliance with the exercise regime and adverse incidents. Additionally, we will assess the usability and acceptability of the intervention device and the performance of different clinical outcome measures (e.g. chin tuck strength, Functional Oral Intake Scale, SWAL-QOL, EQ-5D and swallow speed). A sub-sample of study participants will complete videofluoroscopic assessments of swallowing function before and after the intervention to evaluate the physiological changes (e.g. bolus flow rates, laryngeal elevation, base-of-tongue retraction). CONCLUSIONS: By improving the ability to swallow, using our chin tuck exercise intervention, in frail older patients admitted to hospital with pneumonia, it is anticipated that patients' oral intake will improve. It is suggested that this will further impact clinical, patient and healthcare economic outcomes, i.e. reduce the need for supplemental feeding, improve patient satisfaction with oral intake and swallowing-related quality of life, decrease the occurrence of chest infections and reduce hospital admissions and related healthcare costs. TRIAL REGISTRATION: ISRCTN, ISRCTN12813363 . Registered on 20 January 2020.

Performance of the SarQoL quality of life tool in a UK population of older people with probable sarcopenia and implications for use in clinical trials: findings from the SarcNet registry.

BACKGROUND: The Sarcopenia Quality of Life (SarQoL) questionnaire is a disease-specific sarcopenia quality of life tool. We aimed to independently assess SarQoL with a particular focus on its suitability as a clinical trial outcome measure. METHODS: We analysed data from the UK Sarcopenia Network and Registry. Measures of physical performance and lean mass were collected at baseline. SarQoL and the Strength, Assistance, Rise, Climb - Falls (SARC-F) questionnaire (to assess functional ability) were collected at both baseline and six-month follow-up. Global changes in fitness and quality of life at 6 months were elicited on seven-point Likert scales. Internal consistency was assessed using Cronbach's alpha. Responsiveness (Cohen's d and Guyatt coefficients) and minimum clinically important differences were calculated for participants reporting slight improvement or worsening in their global scores. Concurrent validity was assessed by correlating baseline SarQoL scores with measures of physical performance and functional ability. RESULTS: We analysed data from 147 participants, 125 of whom underwent follow up assessment; mean age 78 years; 72 (49%) were women. Internal consistency was good; Cronbach's alpha was 0.944 at baseline and 0.732 at telephone follow-up. Correlation between baseline and follow-up SarQoL was weak (r = 0.27; p = 0.03). The minimum clinically important improvement ranged from 5 to 21 points giving trial sample size estimates of 25-100 participants. SarQoL scores were moderately correlated with handgrip (r = 0.37; p < 0.001), SARC-F (r = - 0.45; p < 0.001), short physical performance battery (r = 0.48; p < 0.001) and 4-m walk speed (r = 0.48; p < 0.001). CONCLUSIONS: SarQoL has acceptable performance in older UK participants with probable sarcopenia and is sufficiently responsive for use in clinical trials for sarcopenia.

Identifying Dysphagia and Demographic Associations in Older Adults Using Electronic Health Records: A National Longitudinal Observational Study in Wales (United Kingdom) 2008-2018.

Dysphagia is increasingly being recognised as a geriatric syndrome (giant). There is limited research on the prevalence of dysphagia using electronic health records. To investigate associations between dysphagia, as recorded in electronic health records and age, frailty using the electronic frailty index, gender and deprivation (Welsh index of multiple deprivation). A Cross-sectional longitudinal cohort study in over 400,000 older adults was undertaken (65 +) in Wales (United Kingdom) per year from 2008 to 2018. We used the secure anonymised information linkage databank to identify dysphagia diagnoses in primary and secondary care. We used chi-squared tests and multivariate logistic regression to investigate associations between dysphagia diagnosis and age, frailty (using the electronic Frailty index), gender and deprivation. Data indicated < 1% of individuals were recorded as having a dysphagia diagnosis per year. We found dysphagia to be statistically significantly associated with older age, more severe frailty and individuals from more deprived areas. Multivariate analyses indicated increased odds ratios [OR (95% confidence intervals)] for a dysphagia diagnosis with increased age [reference 65-74: aged 75-84 OR 1.09 (1.07, 1.12), 85 + OR 1.23 (1.20, 1.27)], frailty (reference fit: mild frailty 2.45 (2.38, 2.53), moderate frailty 4.64 (4.49, 4.79) and severe frailty 7.87 (7.55, 8.21)] and individuals from most deprived areas [reference 5. Least deprived, 1. Most deprived: 1.10 (1.06, 1.14)]. The study has identified that prevalence of diagnosed dysphagia is lower than previously reported. This study has confirmed the association of dysphagia with increasing age and frailty. A previously unreported association with deprivation has been identified. Deprivation is a multifactorial problem that is known to affect health outcomes, and the association with dysphagia should not be a surprise. Research in to this relationship is indicated.

Physical Restraint in the Critical Care Unit: A Narrative Review.

Restraint has been used within health care settings for many centuries. Initially physical restraint (PR) was the method of choice, in present times. Within critical care units PR and chemical restraint are used, frequently in tandem. Restraint is not a benign intervention and PR specifically is associated with physical and psychological trauma towards those receiving it. Healthcare staff also suffer psychological consequences. This paper has reviewed the literature (using the terms 'physical restraint'; 'hospital'; 'care home critical care'; 'intensive care' 'attitudes'; 'knowledge' 'use of'; 'healthcare') to investigate the reasons for the use of restraints, its consequences and the attitudes of healthcare professionals' attitudes towards physical restraint currently present in critical care. Restraint use remains common practice in Critical Care Units (for 'patient safety'), initiated outside of institutional protocols, despite evidence questioning its effectiveness and the resulting harm to patients and staff.

Interventions for Nursing Home Residents with Dysphagia-A Scoping Review.

Oropharyngeal dysphagia is common in nursing home residents. The objective of this scoping review was to summarize and disseminate the findings from the literature on interventions for dysphagia in nursing home residents. Searches were conducted in four databases. The criteria for including the studies were nursing home residents, dysphagia, interventions, original research, published in English, Danish, Norwegian, or Swedish with no restriction placed regarding publication date. Excluded were literature reviews, editorial comments, conference abstracts, protocols, papers not available in full text, and studies with a mixed population, for example, geriatric patients and nursing home residents and where the results were not separated between the groups. A total of 14 papers were included and analyzed. The included papers represented interventions focusing on feeding intervention, oral hygiene, caregiver algorithm, stimulation (taste and smell), teaching the residents what to eat, mobilization of the spine, exercises/training, and positioning. This scoping review identifies sparse knowledge about interventions affecting nursing home residents' dysphagia. But the results indicate that multi-component interventions, including staff training, training of residents, and/or next of kin, might be successful. This scoping review clarifies that there is a need for well-designed studies that uncover which specific interventions have an effect in relation to nursing home residents with dysphagia and can serve as a guide for designing multi-component person-centered intervention studies. Future studies should implement high evidence study designs, define the measures of dysphagia, and quantify the severity of dysphagia, its underlying diseases, and comorbidities.

Developing a UK sarcopenia registry: recruitment and baseline characteristics of the SarcNet pilot.

BACKGROUND: sarcopenia registries are a potential method to meet the challenge of recruitment to sarcopenia trials. We tested the feasibility of setting up a UK sarcopenia registry, the feasibility of recruitment methods and sought to characterise the pilot registry population. METHODS: six diverse UK sites took part, with potential participants aged 65 and over approached via mailshots from local primary care practices. Telephone pre-screening using the SARC-F score was followed by in-person screening and baseline visit. Co-morbidities, medications, grip strength, Short Physical Performance Battery, bioimpedance analysis, Geriatric Depression Score, Montreal Cognitive Assessment, Sarcopenia Quality of Life score were performed and permission sought for future recontact. Descriptive statistics for recruitment rates and baseline measures were generated; an embedded randomised trial examined the effect of a University logo on the primary care mailshot on recruitment rates. RESULTS: sixteen practices contributed a total of 3,508 letters. In total, 428 replies were received (12% response rate); 380 underwent telephone pre-screening of whom 215 (57%) were eligible to attend a screening visit; 150 participants were recruited (40% of those pre-screened) with 147 contributing baseline data. No significant difference was seen in response rates between mailshots with and without the logo (between-group difference 1.1% [95% confidence interval -1.0% to 3.4%], P = 0.31). The mean age of enrollees was 78 years; 72 (49%) were women. In total, 138/147 (94%) had probable sarcopenia on European Working Group on Sarcopenia 2019 criteria and 145/147 (98%) agreed to be recontacted about future studies. CONCLUSION: recruitment to a multisite UK sarcopenia registry is feasible, with high levels of consent for recontact.

COVID-19 Pandemic Healthcare Resource Allocation, Age and Frailty.

The current coronavirus pandemic presents the greatest healthcare crisis in living memory. Hospitals across the world have faced unprecedented pressure. In the face of this tidal wave of demand for limited healthcare resources, how are clinicians to identify patients most likely to benefit? Should age or frailty be discriminators? This paper seeks to analyse the current evidence-base, seeking a nuanced approach to pandemic decision-making, such as admission to critical care.

Age, Frailty, Resuscitation and Intensive Care: With Reference to COVID-19.

Discussion regarding cardiopulmonary resuscitation and admission to an intensive care unit is frequently fraught in the context of older age. It is complicated by the fact that the presence of multiple comorbidities and frailty adversely impact on prognosis. Cardiopulmonary resuscitation and mechanical ventilation are not appropriate for all. Who decides and how? This paper discusses the issues, biases, and potential harms involved in decision-making. The basis of decision making requires fairness in the distribution of resources/healthcare (distributive justice), yet much of the printed guidance has taken a utilitarian approach (getting the most from the resource provided). The challenge is to provide a balance between justice for the individual and population justice.