Managing loneliness: a qualitative study of older people's views.

Engaging with older people who self-identify as lonely may help professionals in mental health and other services understand how they deal with loneliness. The evidence-base for effective interventions to address loneliness is inconclusive. This study aimed to explore how community-dwelling lonely older people in England manage their experiences of loneliness. Twenty eight community-dwelling older people identifying as lonely, based on responses to two loneliness measures (self-report and a standardised instrument), participated in in-depth interviews between 2013 and 2014. Fifteen lived alone. Thematic analysis of transcribed interviews was conducted by a multidisciplinary team including older people.Participants drew on a range of strategies to ameliorate their distress which had been developed over their lives and shaped according to individual coping styles and contexts. Strategies included physical engagement with the world beyond their home, using technologies, planning, and engagement with purpose in an 'outside world', and acceptance, endurance, revealing and hiding, positive attitude and motivation, and distraction within an 'inside world'. Strategies of interests and hobbies, comparative thinking, religion and spirituality and use of alcohol straddled both the inside and outside worlds. Participants conveyed a personal responsibility for managing feelings of loneliness rather than relying on others. This study includes the experiences of those living with loneliness whilst also living with other people. When developing policy and practice responses to loneliness it is important to listen attentively to the views of those who may not be engaging with services designed for 'the lonely' and to consider their own strategies for managing it.

Implementation fidelity of the Falls Management Exercise Programme: a mixed methods analysis using a conceptual framework for implementation fidelity.

OBJECTIVES: Falls in older adults cause significant morbidity and mortality and incur cost to health and care services. The Falls Management Exercise (FaME) programme is a 24-week intervention for older adults that, in clinical trials, improves balance and functional strength and leads to fewer falls. Similar but more modest outcomes have been found when FaME is delivered in routine practice. Understanding the degree to which the programme is delivered with fidelity is important if 'real-world' delivery of FaME is to achieve the same magnitude of outcome as in clinical trials. The objective of this study was to examine the implementation fidelity of FaME when delivered in the community to inform quality improvement strategies that maximise programme effectiveness. STUDY DESIGN: A mixed methods implementation study of FaME programme delivery. METHODS: Data from programme registers, expert observations of FaME classes, and semistructured interviews with FaME instructors were triangulated using a conceptual framework for implementation fidelity. Quantitative data were analysed using descriptive statistics. Interviews were transcribed verbatim and analysed using thematic analysis. RESULTS: In total, 356 participants enrolled on 29 FaME programmes, and 143 (40%) participants completed at least 75% of the classes within a programme. Observations showed that 72%-78% of programme content was delivered, and 80%-84% quality criteria were met. Important content that was most often left out included home exercises, Tai Chi moves, and floor work, whereas quality items most frequently missed out included asking about falls in the previous week, following up attendance absence and explaining the purpose of exercises. Only 24% of class participants made the expected strength training progression. Interviews with FaME instructors helped explain why elements of programme content and quality were not delivered. Strategies for improving FaME delivery were established and helped to maintain quality and fidelity. CONCLUSIONS: FaME programmes delivered in the 'real world' can be implemented with a high degree of fidelity, although important deviations were found. Facilitation strategies could be used to further improve programme fidelity and maximise participant outcomes.

Keeping active: maintenance of physical activity after exercise programmes for older adults.

OBJECTIVES: To explore factors associated with maintenance of moderate-to-vigorous physical activity (MVPA) in community-dwelling adults aged ≥65 years after completing a 24-week exercise programme. STUDY DESIGN: This is a cohort study nested within a randomised controlled trial evaluating group- and home-based exercise programmes for older people in England. METHODS: MVPA levels and factors potentially associated with physical activity (PA) were self-reported at recruitment, 6, 12, 18 and 24 months after exercise programme. Multilevel logistic regression estimated odds ratios (ORs) for achieving target MVPA level (150 min/week) 6-24 months after exercise programmes ended. RESULTS: Older people (OR per year increase: 0.89, 95% confidence interval [CI] 0.86, 0.93) and women (OR 0.47, 95% CI 0.33, 0.67) were less likely to achieve target MVPA. Those physically active at recruitment (OR 11.28, 95% CI 7.95, 16.01), with wider social networks (OR per unit increase in Lubben Social Network Scale: 1.06, 95% CI 1.03, 1.10) and performing more sit-to-stands in 30 s (OR for quartile 3 compared with quartile 1: 1.87, 95% CI 1.12, 3.10), were more likely to achieve target MVPA. Negative exercise expectations increased the odds of achieving target MVPA but only among the less active at recruitment (OR per unit increase in Outcome and Expectation for Exercise negative subscale: 1.90, 95% CI 1.39, 2.60). Associations did not differ significantly across the follow-up period. CONCLUSION: A range of factors are associated with maintenance of PA 6-24 months after exercise programmes. Factors are not more strongly associated with shorter vs longer term PA maintenance. Commissioners and providers should consider targeting maintenance interventions to those least likely to maintain PA.

Predicting dementia risk in primary care: development and validation of the Dementia Risk Score using routinely collected data.

BACKGROUND: Existing dementia risk scores require collection of additional data from patients, limiting their use in practice. Routinely collected healthcare data have the potential to assess dementia risk without the need to collect further information. Our objective was to develop and validate a 5-year dementia risk score derived from primary healthcare data. METHODS: We used data from general practices in The Health Improvement Network (THIN) database from across the UK, randomly selecting 377 practices for a development cohort and identifying 930,395 patients aged 60-95 years without a recording of dementia, cognitive impairment or memory symptoms at baseline. We developed risk algorithm models for two age groups (60-79 and 80-95 years). An external validation was conducted by validating the model on a separate cohort of 264,224 patients from 95 randomly chosen THIN practices that did not contribute to the development cohort. Our main outcome was 5-year risk of first recorded dementia diagnosis. Potential predictors included sociodemographic, cardiovascular, lifestyle and mental health variables. RESULTS: Dementia incidence was 1.88 (95% CI, 1.83-1.93) and 16.53 (95% CI, 16.15-16.92) per 1000 PYAR for those aged 60-79 (n = 6017) and 80-95 years (n = 7104), respectively. Predictors for those aged 60-79 included age, sex, social deprivation, smoking, BMI, heavy alcohol use, anti-hypertensive drugs, diabetes, stroke/TIA, atrial fibrillation, aspirin, depression. The discrimination and calibration of the risk algorithm were good for the 60-79 years model; D statistic 2.03 (95% CI, 1.95-2.11), C index 0.84 (95% CI, 0.81-0.87), and calibration slope 0.98 (95% CI, 0.93-1.02). The algorithm had a high negative predictive value, but lower positive predictive value at most risk thresholds. Discrimination and calibration were poor for the 80-95 years model. CONCLUSIONS: Routinely collected data predicts 5-year risk of recorded diagnosis of dementia for those aged 60-79, but not those aged 80+. This algorithm can identify higher risk populations for dementia in primary care. The risk score has a high negative predictive value and may be most helpful in 'ruling out' those at very low risk from further testing or intensive preventative activities.

Socio-demographic characteristics, lifestyle factors and burden of morbidity associated with self-reported hearing and vision impairments in older British community-dwelling men: a cross-sectional study.

BACKGROUND: Hearing and vision problems are common in older adults. We investigated the association of self-reported sensory impairment with lifestyle factors, chronic conditions, physical functioning, quality of life and social interaction. METHODS: A population-based cross-sectional study of participants of the British Regional Heart Study aged 63-85 years. RESULTS: A total of 3981 men (82% response rate) provided data. Twenty-seven per cent (n = 1074) reported hearing impairment including being able to hear with aid (n = 482), being unable to hear (no aid) (n = 424) and being unable to hear despite aid (n = 168). Three per cent (n = 124) reported vision impairment. Not being able to hear, irrespective of use of hearing aid, was associated with poor quality of life, poor social interaction and poor physical functioning. Men who could not hear despite hearing aid were more likely to report coronary heart disease (CHD) [age-adjusted odds ratios (ORs) 1.89 (95% confidence interval 1.36-2.63)]. Vision impairment was associated with symptoms of CHD including breathlessness [OR 2.06 (1.38-3.06)] and chest pain [OR 1.58 (1.07-2.35)]. Vision impairment was also associated with poor quality of life, poor social interaction and poor physical functioning. CONCLUSIONS: Sensory impairment is associated with poor physical functioning, poor health and poor social interaction in older men. Further research is warranted on pathways underlying these associations.

The potential of case management for people with dementia: a commentary.

BACKGROUND: A recent review of studies of case management in dementia argues that lack of evidence of cost-effectiveness should discourage the use of this approach to care. We argue that that this is too conservative a stance, given the urgent need throughout the world to improve the quality of care for people with dementia and their caregivers. We propose a research agenda on case management for people with dementia. METHOD: A critical comparison was made of the studies identified in two systematic reviews of trials of case management for dementia, with selective inclusion of non-trial studies and economic evaluations. RESULTS: Our interpretation of the literature leads us to four provisional conclusions. First, studies with long follow-up periods tend to show delayed relocation of people with dementia to care homes. Second, the quality of life of people with dementia and their caregivers may also influence the likelihood of relocation. Third, different understandings of what constitutes case management make interpretation of studies difficult. Fourth, we agree that the population most likely to benefit from case management needs to be characterised. Earlier intervention may be more beneficial than intervening when the condition has progressed and the individual's situation is highly complex. However, this runs counter to some definitions of case management as an administrative, professional, and systemic focus on people with high needs and where expensive support is accessed or in prospect. CONCLUSIONS: More work needs to be carried out in a more focused way in order to establish the value of case management for people with dementia. Since care home residence is such a sizeable contributor to the costs of dementia care, studies need to be long enough to capture possible postponed relocation. However, case management studies with shorter follow-up periods can still contribute to our understanding, since they can demonstrate improved quality of life. Future research should be built around a common, agreed definition of types of case management.

The effect of exercise on behavioral and psychological symptoms of dementia: towards a research agenda.

BACKGROUND: Behavioral and psychological symptoms of dementia (BPSD) are common and are core symptoms of the condition. They cause considerable distress to the person with dementia and their carers and predict early institutionalization and death. Historically, these symptoms have been managed with anxiolytic and antipsychotic medication. Although potentially effective, such medication has been used too widely and is associated with serious adverse side-effects and increased mortality. Consequently, there is a need to evaluate non-pharmacological therapies for behavioral and psychological symptoms in this population. One such therapy is physical activity, which has widespread health benefits. The aim of this review is to summarize the current findings of the efficacy of physical activity on BPSD. METHOD: Published articles were identified using electronic and manual searches. Rather than systematically aggregating data, this review adopted a rapid critical interpretive approach to synthesize the literature. RESULTS: Exercise appears to be beneficial in reducing some BPSD, especially depressed mood, agitation, and wandering, and may also improve night-time sleep. Evidence of the efficacy of exercise on improving other symptoms such as anxiety, apathy, and repetitive behaviors is currently weak or lacking. CONCLUSION: The beneficial effect of exercise type, its duration, and frequency is unclear although some studies suggest that walking for at least 30 minutes, several times a week, may enhance outcome. The methodological shortcomings of current work in this area are substantial. The research and clinical implications of current findings are discussed.

The primary care diagnosis of dementia in Europe: an analysis using multidisciplinary, multinational expert groups.

OBJECTIVES: To explore the extent of variation in the detection of dementia in primary care across Europe, and the potential for the development of European guidelines. METHOD: A mixture of focus group and adapted nominal group methods involving 23 experts of different disciplines and from eight European countries. RESULTS: The diagnosis of dementia should be 'timely' rather than 'early'. Timeliness has an impact on the patient, on the caregiver, on healthcare professionals, and on society. Ethical and moral issues may interfere with the aim of timely diagnosis. Guidelines may be important for facilitating a timely diagnosis of dementia, but were infrequently used and not even available in three of the eight countries. Referral pathways often depended on health care system characteristics, differing throughout the eight European countries, whilst diagnostic strategies differed due to varied cultural influences. There was consensus that national variations can be reduced and timely diagnosis enhanced by combining simple tests using a systematic stepwise case-finding strategy, in conjunction with a strong infrastructure of multidisciplinary collaboration. CONCLUSIONS: This study identified three key themes that should be considered in harmonizing European approaches to the diagnosis of dementia in primary care: (1) a focus on timely diagnosis, (2) the need for the development and implementation of guidelines, and (3) the identification of appropriate referral pathways and diagnostic strategies including multi-professional collaboration. The content of guidelines may be determined by the perspectives of the guideline developers.

Fruit and Vegetable Consumption and Frailty: A Systematic Review.

OBJECTIVE: To identify currently available evidence on fruit and vegetable consumption in association with frailty by conducting a systematic review of the literature and to summarise and critically evaluate it. DESIGN: Systematic review. SETTING: Four electronic databases (Embase, MEDLINE, CINAHL and PsycINFO) were systematically searched in August 2017 for observational cohort studies providing cross-sectional or prospective associations between fruit and vegetable consumption and frailty risks. Additional studies were searched by manually reviewing the reference lists of the included studies and related review papers and conducting forward citation tracking of the included studies. The methodological quality of prospective studies was assessed using the Newcastle-Ottawa scale. PARTICIPANTS: Community-dwelling general populations. RESULTS: A total of 6251 studies were identified, of which five prospective studies with follow-up periods of 2-10.5 years and two cross-sectional studies were included. Among the five prospective studies, three had adequate methodological quality. Because of different measurements and statistical methodologies, a meta-analysis was not possible. The two studies of good quality showed that fruit and vegetable consumption was mostly associated with lower risk of incident frailty. The other study as a sub-analysis retrospectively examined baseline fruit and vegetable consumption of those who developed frailty and those who did not at follow-up and showed no significant associations. CONCLUSIONS: Although good quality studies on this topic are scarce, there is some suggestion that higher fruit and vegetable consumption may be associated with lower frailty risk. More high quality research is needed.

Community screening for visual impairment in the elderly.

BACKGROUND: While the aims of multicomponent screening of older people are broad, any benefit arising from the inclusion of a vision component in the assessment will necessarily be dependent on improving vision. OBJECTIVES: To assess the effects on vision of mass screening of older people for visual impairment. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which contains the Cochrane Eyes and Vision Group Trials Register, in The Cochrane Library (Issue 1, 2006), NRR (Issue 1, 2006), MEDLINE (1966 to February 2006), EMBASE (1980 to February 2006), PubMed (on 8th March; last 90 days), SciSearch and reference lists of relevant trial reports and review articles. We contacted investigators to identify additional published and unpublished trials. SELECTION CRITERIA: We included randomised trials of visual or multicomponent screening for identifying vision impairment in people aged 65 years or over in a community setting. DATA COLLECTION AND ANALYSIS: Both authors independently extracted data and assessed trial quality. MAIN RESULTS: Visual outcome data were available for 3494 people in five trials of multicomponent assessment. Length of follow up ranged from two to four years. All the trials used self-reported measures for visual impairment, both as screening tools and as outcome measures. In four of the trials people reporting visual problems were referred to either eye services or a physician. In one trial people reporting visual problems received information about resources in the community designed to assist those with poor vision. The proportions of participants in the intervention and control groups who reported visual problems at the time of outcome assessment were 0.26 and 0.23 respectively (risk ratio for visual impairment 1.03, 95% confidence interval (CI) 0.92 to 1.15). Visual outcome data were also available for 1807 people aged 75 years and over in a cluster randomised trial in which physicians' general practices were randomised to two different screening strategies; universal or targeted. Three to five years after screening, the risk ratio for visual acuity less than 6/18 in either eye comparing universal with targeted screening was 1.07 (95% CI 0.84 to 1.36, P = 0.58). The mean composite score of the National Eye Institute 25 item visual function questionnaire was 85.6 in the targeted screening group and 86.0 in the universal group, a difference of 0.4 (95% CI -1.7 to 2.5, P = 0.69). AUTHORS' CONCLUSIONS: There is no evidence that community-based screening of asymptomatic older people results in improvements in vision.

Making decisions at the end of life when caring for a person with dementia: a literature review to explore the potential use of heuristics in difficult decision-making.

OBJECTIVE: Decision-making, when providing care and treatment for a person with dementia at the end of life, can be complex and challenging. There is a lack of guidance available to support practitioners and family carers, and even those experienced in end of life dementia care report a lack of confidence in decision-making. It is thought that the use of heuristics (rules of thumb) may aid decision-making. The aim of this study is to identify whether heuristics are used in end of life dementia care, and if so, to identify the context in which they are being used. DESIGN: A narrative literature review was conducted taking a systematic approach to the search strategy, using the Centre for Reviews and Dissemination guidelines. Rapid appraisal methodology was used in order to source specific and relevant literature regarding the use of heuristics in end of life dementia care. DATA SOURCES: A search using terms related to dementia, palliative care and decision-making was conducted across 4 English language electronic databases (MEDLINE, EMBASE, PsycINFO and CINAHL) in 2015. RESULTS: The search identified 12 papers that contained an algorithm, guideline, decision tool or set of principles that we considered compatible with heuristic decision-making. The papers addressed swallowing and feeding difficulties, the treatment of pneumonia, management of pain and agitation, rationalising medication, ending life-sustaining treatment, and ensuring a good death. CONCLUSIONS: The use of heuristics in palliative or end of life dementia care is not described in the research literature. However, this review identified important decision-making principles, which are largely a reflection of expert opinion. These principles may have the potential to be developed into simple heuristics that could be used in practice.

Reducing falls among older people in general practice: The ProAct65+ exercise intervention trial.

BACKGROUND: Falls are common in the older UK population and associated costs to the NHS are high. Systematic reviews suggest that home exercise and group-based exercise interventions, which focus on progressively challenging balance and increasing strength, can reduce up to 42% of falls in those with a history of falls. The evidence is less clear for those older adults who are currently at low risk of falls. AIM: ProAct65+, a large, cluster-randomised, controlled trial, investigated the effectiveness of a home exercise programme (Otago Exercise Programme (OEP)) and a group-based exercise programme (Falls Management Exercise (FaME)) compared to usual care (UC) at increasing moderate to vigorous physical activity (MVPA). This paper examines the trial's secondary outcomes; the effectiveness of the interventions at reducing falls and falls-related injuries. SETTING & PARTICIPANTS: 1256 community-dwelling older adults (aged 65+) were recruited through GP practices in two sites (London and Nottingham). Frequent fallers (≥3 falls in last year) and those with unstable medical conditions were excluded, as were those already reaching the UK Government recommended levels of physical activity (PA) for health. METHODS: Baseline assessment (including assessment of health, function and previous falls) occurred before randomisation; the intervention period lasted 24 weeks and there was an immediate post-intervention assessment; participants were followed up every six months for 24 months. Falls data were analysed using negative binomial modelling. OUTCOME MEASURES: Falls data were collected prospectively during the intervention period by 4-weekly diaries (6 in total). Falls recall was recorded at the 3-monthly follow-ups for a total of 24 months. Balance was measured at baseline and at the end of the intervention period using the Timed Up & Go and Functional Reach tests. Balance confidence (CONFbal), falls risk (FRAT) and falls self-efficacy (FES-I) were measured by questionnaire at baseline and at all subsequent assessment points. RESULTS: 294 participants (24%) reported one or two falls in the previous year. There was no increase in falls in either exercise group compared to UC during the intervention period (resulting from increased exposure to risk). The FaME arm experienced a significant reduction in injurious falls compared to UC (incidence rate ratio (IRR) 0.55, 95% CI 0.31, 0.96; p=0.04) and this continued during the 12 months after the end of the intervention (IRR 0.73, 95% CI 0.54, 0.99; p=0.05). There was also a significant reduction in the incidence of all falls (injurious and non-injurious) in the FaME arm compared with UC (IRR 0.74, 95% CI 0.55, 0.99; p=0.04) in the 12 month period following the cessation of the intervention. There was a non-significant reduction in the incidence of all falls in the OEP arm compared with UC (IRR 0.76, 95% CI 0.53, 1.09; p=0.14) in the 12 months following the cessation of the intervention. The effects on falls did not persist at the 24 months assessment in either exercise arm. However, when those in the FaME group who continued to achieve 150min of MVPA per week into the second post-intervention year were compared to those in the FaME group who did not maintain their physical activity, there was a significant reduction in falls incidence (IRR=0.49, 95% CI 0.30, 0.79; p=0.004). CONFbal was significantly improved at 12 months post intervention in both intervention arms compared with UC. There were no significant changes in any of the functional balance measures, FES-I or FRAT, between baseline and the end of the intervention period. CONCLUSION: Community-dwelling older adults who joined an exercise intervention (FaME) aimed at increasing MVPA did not fall more during the intervention period, fell less and had fewer injurious falls in the 12 months after cessation of the intervention. However, 24 months after cessation of exercise, the beneficial effects of FaME on falls reduction ceased, except in those who maintained higher levels of MVPA. OEP exercise appears less effective at reducing falls in this functionally more able population of older adults.

Physiological correlates of cognitive functioning in an elderly population.

Cognitive decline in old age is not universal or inevitable. Associations have been observed with neuroendocrine function, but the relevance of other physiological processes is unclear. We predicted that impairment of memory in an ageing population would be related to the dysregulation of neuroendocrine and cardiovascular responses. One hundred and thirty-nine participants (65-80 years) were recruited from general practice in London. Two standardised verbal paired-associates recall tasks were administered in order to determine declarative memory performance, and a fluid intelligence task (matrix reasoning) was also performed. Salivary cortisol samples were collected every 10 min, while blood pressure and heart rate were measured before, during and after each task. Illness history and medication use were obtained from medical records. Multiple linear regression analysis, adjusted for age, gender, education, chronic illness, and medication use, revealed that cortisol responses were inversely related to memory performance. Additionally, superior memory was associated with more effective post-task recovery of heart rate (in both men and women) and diastolic blood pressure recovery in men. Cardiovascular recovery effects were independent of covariates, and of levels of heart rate and blood pressure measured during tasks themselves. These associations were also independent of subjective ratings of stress and perceived performance. Neither neuroendocrine nor cardiovascular responses were related to performance of the reasoning task. We conclude that memory in the elderly is associated both with hypothalamic-pituitary-adrenocortical function and cardiovascular regulation. Disturbances of neuroendocrine and hemodynamic function may be related to greater vulnerability to cognitive decline.

Hospital at home versus in-patient hospital care.

BACKGROUND: Hospital at home is defined as a service that provides active treatment by health care professionals, in the patient's home, of a condition that otherwise would require acute hospital in-patient care, always for a limited period. OBJECTIVES: To assess the effects of hospital at home compared with in-patient hospital care. SEARCH STRATEGY: We searched the Cochrane Effective Practice and Organisation of Care Group (EPOC) specialised register (November 2004), MEDLINE (1966 to 1996), EMBASE (1980 to 1995), Social Science Citation Index (1992 to 1995), Cinahl (1982 to 1996), EconLit (1969 to 1996), PsycLit (1987 to 1996), Sigle (1980 to 1995) and the Medical Care supplement on economic literature (1970 to 1990). SELECTION CRITERIA: Randomised trials of hospital at home care compared with acute hospital in-patient care. The participants were patients aged 18 years and over. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and assessed study quality. MAIN RESULTS: Twenty two trials are included in this update of the review. Among trials evaluating early discharge hospital at home schemes we found an odds ratio (OR) for mortality of 1.79 95% CI 0.85 to 3.76 for elderly medical patients (age 65 years and over) (n = 3 trials); OR 0.58; 95% CI 0.29 to 1.17 for patients with chronic obstructive pulmonary disease (COPD) (n = 5 trials); and OR 0.78; 95%CI 0.52 to 1.19 for patients recovering from a stroke (n = 4 trials). Two trials evaluating the early discharge of patients recovering from surgery reported an OR 0.43 (95% CI 0.02 to 10.89) for patients recovering from a hip replacement and an OR 1.01 (95% CI 0.37 to 2.81) for patients with a mix of conditions at three months follow-up. For readmission to hospital we found an OR 1.76; 95% CI 0.78 to 3.99 at 3 months follow-up for elderly medical patients (n = 2 trials); OR 0.81; 95% CI 0.55 to 1.19 for patients with COPD (n = 5 trials); and OR 0.96; 95% CI 0.63 to 1.45 for patients recovering from a stroke (n = 3 trials). No significant heterogeneity was observed. One trial recruiting patients following surgery for hernia or varicose veins reported 0/117 versus 2/121 patients were re admitted (Ruckley 1978); another that 2/37 (5%) versus 1/49 (2%) (difference 3%, 95% CI -5% to 12%) of patients recovering from a hip replacement, 4/47 (9%) versus 1/39 (3%) (difference 6%, 95% CI -3% to 15%) of patients recovering from a knee replacement, and 7/114 (6%) versus 13/124 (10%) (difference -4% 95% CI -11% to 3%) of patients recovering from a hysterectomy were readmitted. A third trial analysing surgical and medical patients together reported that 42/159 versus 17/81 patients were readmitted at 3 months (OR 1.34 95% CI 0.66 to 2.20). Allocation to hospital at home resulted in a small reduction in hospital length of stay, but hospital at home increased overall length of care. Patients allocated to hospital at home expressed greater satisfaction with care than those in hospital, while the view of carers was mixed. AUTHORS' CONCLUSIONS: Despite increasing interest in the potential of hospital at home services as a cheaper alternative to in-patient care, this review provides insufficient objective evidence of economic benefit. Early discharge schemes for patients recovering from elective surgery and elderly patients with a medical condition may have a place in reducing the pressure on acute hospital beds, providing the views of the carers are taken into account. For these clinical groups hospital length of stay is reduced, although this is offset by the provision of hospital at home. Future primary research should focus on rigorous evaluations of admission avoidance schemes and standards for original research should aim at assisting future meta-analyses of individual patient data from these and future trials.

Health risk appraisal for older people in general practice using an expert system: a pilot study.

The prevention of disability in later life is a major challenge facing industrialised societies. Primary care practitioners are well positioned to maintain and promote health in older people, but the British experience of population-wide preventive interventions has been disappointing. Health risk appraisal (HRA), an emergent information-technology-based approach from the USA, has the potential for fulfilling some of the objectives of the National Service Framework for Older People. Information technology and expert systems allow the perspectives of older people on their health and health risk behaviours to be collated, analysed and converted into tailored health promotion advice without adding to the workload of primary care practitioners. The present paper describes a preliminary study of the portability of HRA to British settings. Cultural adaptation and feasibility testing of a comprehensive health risk assessment questionnaire was carried out in a single group practice with 12,500 patients, in which 58% of the registered population aged 65 years and over participated in the study. Eight out of 10 respondents at all ages found the questionnaire easy or very easy to understand and complete, although more than one-third had or would have liked assistance. More than half felt that the length of the questionnaire was about right, and one respondent in 10 disliked some questions. Of those who completed the questionnaire and received tailored, written health promotion advice, 39% provided feedback on this with comments that can be used for increasing the acceptability of tailored advice. These findings have informed a wider exploratory study in general practice.

After the Liverpool Care Pathway--development of heuristics to guide end of life care for people with dementia: protocol of the ALCP study.

INTRODUCTION: End of life care guidance for people with dementia is lacking and this has been made more problematic in England with the removal of one of the main end of life care guidelines which offered some structure, the Liverpool Care Pathway. This guidance gap may be eased with the development of heuristics (rules of thumb) which offer a fast and frugal form of decision-making. OBJECTIVE: To develop a toolkit of heuristics (rules of thumb) for practitioners to use when caring for people with dementia at the end of life. METHOD AND ANALYSIS: A mixed-method study using a co-design approach to develop heuristics in three phases. In phase 1, we will conduct at least six focus groups with family carers, health and social care practitioners from both hospital and community care services, using the 'think-aloud' method to understand decision-making processes and to develop a set of heuristics. The focus group topic guide will be developed from the findings of a previous study of 46 interviews of family carers about quality end-of-life care for people with dementia and a review of the literature. A multidisciplinary development team of health and social care practitioners will synthesise the findings from the focus groups to devise and refine a toolkit of heuristics. Phase 2 will test the use of heuristics in practice in five sites: one general practice, one community nursing team, one hospital ward and two palliative care teams working in the community. Phase 3 will evaluate and further refine the toolkit of heuristics through group interviews, online questionnaires and semistructured interviews. ETHICS AND DISSEMINATION: This study has received ethical approval from a local NHS research ethics committee (Rec ref: 15/LO/0156). The findings of this study will be presented in peer-reviewed publications and national and international conferences.

Cardiovascular risk profile and frailty in a population-based study of older British men.

BACKGROUND: Frailty in older age is known to be associated with cardiovascular disease (CVD) risk. However, the extent to which frailty is associated with the CVD risk profile has been little studied. Our aim was to examine the associations of a range of cardiovascular risk factors with frailty and to assess whether these are independent of established CVD. METHODS: Cross-sectional study of a socially representative sample of 1622 surviving men aged 71-92 examined in 2010-2012 across 24 British towns, from a prospective study initiated in 1978-1980. Frailty was defined using the Fried phenotype, including weight loss, grip strength, exhaustion, slowness and low physical activity. RESULTS: Among 1622 men, 303 (19%) were frail and 876 (54%) were pre-frail. Compared with non-frail, those with frailty had a higher odds of obesity (OR 2.03, 95% CI 1.38 to 2.99), high waist circumference (OR 2.30, 95% CI 1.67 to 3.17), low high-density lipoprotein-cholesterol (HDL-C) (OR 2.28, 95% CI 1.47 to 3.54) and hypertension (OR 1.79, 95% CI 1.27 to 2.54). Prevalence of these factors was also higher in those with frailty (prevalence in frail vs non-frail groups was 46% vs 31% for high waist circumference, 20% vs 11% for low HDL and 78% vs 65% for hypertension). Frail individuals had a worse cardiovascular risk profile with an increased risk of high heart rate, poor lung function (forced expiratory volume in 1 s (FEV1)), raised white cell count (WCC), poor renal function (low estimated glomerular filtration rate), low alanine transaminase and low serum sodium. Some risk factors (HDL-C, hypertension, WCC, FEV1, renal function and albumin) were also associated with being pre-frail. These associations remained when men with prevalent CVD were excluded. CONCLUSIONS: Frailty was associated with increased risk of a range of cardiovascular factors (including obesity, HDL-C, hypertension, heart rate, lung function, renal function) in older people; these associations were independent of established CVD.

The community prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in older people living in their own homes: implications for treatment, screening and surveillance in the UK.

Methicillin-resistant Staphylococcus aureus (MRSA) predominantly affects those over 65 years old. There may be a substantial pool of older people with MRSA in the community. We studied the prevalence in one London general practice, screening 258 older people living in their own home. MRSA (E-MRSA 15) was found in two participants (0.78%). Past history of MRSA was the only significant risk factor. The results of this and other studies suggest that national guidelines recommending early discharge for MRSA carriers have not resulted in widespread community acquisition amongst elderly people living in their own home. Community antibiotic policies for skin and soft-tissue infection do not require amendment. Patients with previous MRSA should be isolated and screened on admission especially to high-risk units.

Evaluation of the use of brief screening instruments for dementia, depression and problem drinking among elderly people in general practice.

BACKGROUND: Use of brief screening instruments for detection of psychological morbidity among elderly people is being promoted, although the appropriateness and effectiveness of available instruments have not been evaluated in general practice. AIM: This study set out to determine the outcome of opportunistic use of brief screening instruments for dementia, depression and problem drinking in randomized trials in two group practices in north west London. METHOD: Screening instruments were inserted into a random sample of medical records for people aged 75 years and over in each practice. Medical records of those seen by their general practitioners over a six month period were reviewed for new diagnoses of dementia (or confusion), depression or problem drinking, and the scores obtained on screening instruments noted. The records of all those identified as possibly demented, depressed or drinking heavily were reviewed one year after screening and all relevant referrals and new treatments were noted. RESULTS: In one practice use of screening instruments resulted in a significant increase in the detection of possible dementia, but not of depression. In the second practice screening instruments yielded significantly higher numbers with possible dementia or depression. Heavy drinking was uncommon in either population. There was no difference in the proportions of cases identified by screening instrument or by clinical judgement alone who received treatment or referral. CONCLUSION: These results suggest that in the absence of agreed guidelines and resources, information derived from screening instruments may not alter clinical practice.