Diarmuid O'Shea

Orthostatic haemodynamics may be impaired in frailty

BACKGROUND orthostatic hypotension (OH) is a physical sign that reflects a final common pathway of various forms of disordered physiology, which is the hallmark of geriatric frailty. Fried et al. recognise three increasing frailty phenotypes in older people, based on measurements of weight loss, exhaustion, grip strength, walking speed and physical activity. Orthostatic haemodynamics have not been considered as markers of frailty in older people. OBJECTIVE to classify a community sample of older people into three increasing frailty phenotypes and compare their orthostatic haemodynamics. DESIGN cross-sectional study. SETTING geriatric research clinic. SUBJECTS a total of 442 subjects (mean age 72, 72% females) without dementia or risk factors for autonomic neuropathy. METHODS the sample was classified according to modified Fried criteria. Orthostatic systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR) responses were monitored during an active stand with Finometer®. RESULTS one hundred and ninety-eight subjects (44.8%) were classified as non-frail, 213 (48.2%) as pre-frail, and 31 (7.0%) as frail. Across groups, there was a significant increasing gradient in baseline HR (P = 0.008) and decreasing gradients in Delta HR (i.e. maximum HR within 30 s-baseline HR) (P < 0.001) and maximum HR by 30 s (P < 0.001). On average, by 30 s after stand, non-frail subjects had recovered 98% of their baseline SBP, while pre-frail and frail subjects had recovered 95 and 92%, respectively (P for trend = 0.064). CONCLUSIONS the orthostatic HR response and, to a lesser extent, SBP recoverability, appear impaired in frailty. Orthostatic haemodynamics may be useful markers of frailty.

Fitness and frailty: opposite ends of a challenging continuum! Will the end of age discrimination make frailty assessments an imperative?

In Europe, those over 65 years of age will increase to 30% of the population over the next 30 years [1]. Those over 75 and especially 85 years of age concentrate the highest proportions of poor health and disability. At the same time, even at the oldest ages, the majority live in noninstitutionalised settings [2]. Increasingly, the ‘demographic time bomb’ concept is being replaced by a more constructive discourse based on the realisation that population ageing is diverse and the association between chronological age and health status is extremely variable [3, 4]. Consequently, the efficient delivery of health and social care services to older people requires a specific focus, for doctors and allied professionals, in responding to this combination of diversity and complexity. The intuitive concepts of ‘fitness’ and ‘resilience’ often underpin decisions on the escalation of medical therapy, as they safeguard against iatrogenesis [5]. On the other hand, those presenting to the acute hospital for medical admission are more likely to suffer from multiple chronic illnesses, polypharmacy, cognitive and functional decline and other geriatric syndromes driven by accumulation of deficits and dysregulation in multiple biological systems. ‘Frail’ individuals are vulnerable and therefore at an increased risk of adverse outcomes (e.g. iatrogenesis, functional decline and death), but also benefit from specialist multidisciplinary care and interventions [6]. However, the identification of those most likely to benefit (and least likely to be harmed) from an intervention remains a challenge: where are they along the fitness-frailty spectrum? In answering the question, chronological age is of little help. Indeed, decisions for clinical treatment based primarily on age are not best suited to the complexity of the human body, especially the complexity of older humans [7]. In the UK, from 1 October 2012, older people will have the right to sue if they have been denied health and/ or social care based on age alone [8]. The Department of Health is committed to rooting out age discrimination and, as far as health or social care services are concerned, there will be no exceptions to the implementation of the Equality Act 2010 [9]. An example of the discrimination the ban aims to end includes ‘making assumptions about whether an older patient should be referred for treatment based solely on their age, rather than on the individual need and fitness level’ [9]. Indeed, any age-based practices by the NHS and social care organisations will need to be objectively justified, if challenged [10]. Therefore, it is likely that the assessment of older people’s ‘fitness level’ will become desirable (if not necessary) in routine health and social care practice. The problem is how to objectively grade that ‘fitness level’ in every specific clinical or social care scenario. ‘Fitness’ and ‘frailty’ are opposite ends of a challenging continuum. While experienced practitioners can (and often do) intuitively place their patients along that imaginary spectrum, that subjective ‘clinical impression’ of vulnerability may not be sufficient in the eyes of the Equality Act 2010. Therefore, formal frailty metrics will be required in health and social care, for various purposes including documentation. However, the objective measurement of frailty has limitations (e.g. some physical performance measures are unfeasible in the very frail [11]). As yet, there is no consensus (nor any official guidance) on which measures may be appropriate for the explicit documentation of frailty status in older people. Recently, the NHS Evidence Adoption Centre published a review of the methods and instruments for identifying frailty, including risk stratification models, performance assessment and self reports [12]. Efforts like the latter will likely be of help to practitioners; however, despite ongoing research efforts, the development and validation of frailty metrics is currently underdeveloped, compared with the clarity of concept and implementation speed of the Equality legislation. Some mismatch may be felt on the ground after 1 October. Overall, the full implementation of the Equality Act 2010 in health and social care is to be welcomed. It will minimise instances of ageism and age discrimination at a time when European populations are getting older in chronological, but not necessarily biological, terms. Developments occur on a background of heightened public expectations and aggressive cost-containment measures, adding to the complexity known to geriatric practitioners. Unintended consequences may or may not ensue, but good documentation will always be good practice, good advocacy and good defence. In the UK, the selection and adoption of appropriate frailty metrics for health and social care will likely become a matter of some urgency as a result of the implementation of this pioneering piece of legislation. In other European countries, geriatric practitioners ‘cannot wait’ to implement

Determinants of short- and long-term survival from colorectal cancer in very elderly patients

PURPOSE Over 5100 colorectal cancers (CRCs) are diagnosed in the United Kingdom in 85 years and older age group per year but little is known of cancer progression in this group. We assessed clinical, pathological and molecular features of CRC with early and late mortality in such patients. METHODS Data were analysed in relation to early mortality and long-term survival in 90 consecutive patients with CRC aged 85 years or older in a single hospital. RESULTS Patients not undergoing operation, those with an ASA score of III or greater and those with advanced tumour stage were more likely to die within 30 days. Regression analysis showed that 30 day mortality was independently related to failure to undergo resection (odds ratio (O.R.), 10.0; 95% confidence interval [C.I.], 1.7-58.2; p=0.01) and an ASA score of III or greater (O.R. 13.0; 95% C.I., 1.4-12.6; p=0.03). All cause three and five year survival were 47% and 23% respectively for patients who are alive 30 days after diagnosis. Three and five year relative survivals were 64% and 54%, respectively. Long-term outcome was independently related to tumour stage (relative risk [R.R.], 2; 95% C.I., 1.3-3.1; p=0.001), presence of co-morbid diseases (R.R., 2.8; 95% C.I., 1.3-6.0; p=0.007) and lipid peroxidation status (R.R., 2.9; 95% C.I., 1.1-7.5; p=0.025). CONCLUSIONS An active multidisciplinary approach to the care of patients with CRC at the upper extreme of life is reasonable. It also seems sensible to individualise care based upon the extent of disease at diagnosis and the presence of co-morbid conditions. Further studies to examine the role of lipid peroxidation are warranted.

Predicting the in‐patient outcomes of acute medical admissions from the nursing home: The experience of St James's Hospital, Dublin, 2002–2010

Aim:  To identify predictors of negative in‐patient outcomes (prolonged hospital stay and death) in nursing home (NH) residents admitted to the hospital as medical emergencies.

Clinical and Pathological Factors Associated with Colorectal Cancer at the Upper Extreme of Life

from the hospital infection control nurse that the patient had trichinosis. Immediately thoughts of pork, eosinophilia, muscle biopsies, other residents who may have eaten the same food, questions of incubation, our food services director, our kitchen, our meat distributors, the department of health, and the news media ran through my head. Luckily, seconds later I realized that a urinalysis and 2 g of metronidazole do not diagnose or treat trichinosis but rather trichomonas. The resident, fully alert and oriented, reported no sexual activity in years and no gynecology evaluation. Chlamydia and gonorrhea studies were determined to be negative. The patient remains asymptomatic of vaginal discharge and muscle pains. Guess what? Further investigation reveals she keeps kosher.

Resilience in family caregiving for people with dementia: A systematic review

The objective of this review is to critically examine, evaluate, and synthesize the literature on resilience in family caregiving for people with dementia.

The systematic approach to improving care for Frail Older Patients (SAFE) study: A protocol for co-designing a frail older person’s pathway

Background: Frailty is the age-accelerated decline across multiple organ systems which leads to vulnerability to poor resolution of homeostasis after a stressor event. This loss of reserve means that a minor illness can result in a disproportionate loss of functional ability. Improving acute care for frail older patients is now a national priority and an important aspect of the National Programme for Older People in Ireland. Evidence suggests that an interdisciplinary approach incorporating rapid comprehensive geriatric assessment and early intervention by an interdisciplinary team can reduces susceptibility to hospitalisation related functional decline. The aim of the Systematic Approach to Improving Care for Frail Older Patients (SAFE) is to develop and explore the process of implementing a model of excellence in the delivery of patient-centred integrated care within the context of frail older people’s acute admissions. Methods: The SAFE study will employ a mixed methodology approach, including a rapid realist review of the current literature alongside a review of baseline data for older people attending the emergency department. Semi-structured interviews will be undertaken to document the current pathway. The intervention processes and outcomes will be jointly co-designed by a patient and public involvement (PPI) group together with the interdisciplinary healthcare professionals from hospital, community and rehabilitation settings. Successive rounds of Plan-Do-Study-Act cycles will then be undertaken to test and refine the pathway for full implementation. Discussion: This research project will result in a plan for implementing an integrated, patient-centred pathway for acute care of the frail older people which has been tested in the Irish setting. During the process of development, each element of the new pathway will be tested in turn to ensure that patient centred outcomes are being realised. This will ensure the resulting model of care is ready for implementation in the context of the Irish health service.

Optimising the Comprehensive Geriatric Assessment

Introduction: Carew House Day Hospital is an outpatient assessment unit for patients aged 65 years and over and is operated by the Medicine for the Elderly service in St. Vincent’s University Hospital (SVUH). Patients attending Carew House undergo multidisciplinary Comprehensive Geriatric Assessment (Medical, Nursing, Physiotherapy, Occupational Therapy and Social Work) with further access to Speech and Language Therapy, Dietician and Smoking Cessation services as required. The service assesses approximately 600 new patients annually. The National Clinical Programme for Older People advocates a Comprehensive Geriatric Assessment (CGA) of frail older patients as a means to increase independence in the home and reduce inappropriate admissions to nursing homes. Short Description of Practice Change Implemented: Deficiencies in the CGA were identified and discussed at a meeting of the Day Hospital Management involving medical, nursing and allied health staff. These deficits were demonstrated through an initial pilot and retrospective review of patients assessed in the Day Hospital. It was recognised that additional resources and staff for the Day Hospital would not be an available option to alleviate this problem. Once deficits in the CGA were identified and outlined, staff were empowered to engage with the change process immediately in order to develop improvement solutions. Aim and Theory of Change: The aim of this project was to empower members of the multidisciplinary team (MDT) to generate efficiencies within the service and to identify areas where the CGA could be streamlined. In December 2014, the following interventions were implemented: A new vetting process for patient referrals to ensure appropriate MDT members would be available on the date of assessment Nomination of designated nurse leader and senior clinician in the absence of regular staff An additional and timely referral pathway for physiotherapy and occupational therapy assessment using pre-existing additional community services Alternative access routes for medical social work input involving redesign of the referral pathway Targeted Population and Stakeholders: This included all patients assessed in Carew House Day Hopsital and all members of the MDT. Timeline: September 2014 - April 2015 Highlights: Having a Consultant’s clinical opinion directly available for each patient increased from 79% to 88%. The presence and input of a Nurse Manager on the day of assessment increased from 30% to 99%. Completion of Physiotherapy and Occupational Therapy assessment for patients increased from 65% to 73%, and 96% to 99% respectively. In addition to these improvements in the CGA, systems were implemented to ensure that a senior clinical opinion (Registrar or Consultant) was available at all times via telephone and a Deputy Nurse Lead was appointed in the absence of a Nurse Manager. An additional 15% of patients received Physiotherapy assessment via the newly implemented alternative referral pathway. Comments on Sustainability: It is recognised that while this suite of interventions has resulted in progress, our service is in constant need of review and regeneration in order to continue to improve for our patients. Comments on Transferability: This change process engaged staff across the MDT and highlighted that positive change in a service is achievable through improving efficiency and redesigning processes, without budgetary expansion. This model is transferable. Conclusions: Changes in Carew House Day Hospital resulted in improvements in the constituents and overall quality of the CGA for our catchment community. Discussions: While this project resulted in some improvement, the main barrier encountered was in recognising the deficits in our service that required change. Lessons Learned: Resource limitations should never stand in the way of improvement!

Re: The impact of cognition on falls prevention programmes

SIR—We read with interest the findings of the paper by Irvine et al. [1]. This paper further highlights the difficulties geriatricians face in finding effective ways to prevent falls in the community. One of the points we felt may have been overlooked was the effect of cognition on the falls rate and future attendance to a falls prevention program. Previous research has shown that cognitive impairment has a significant impact on falls and risk of future falls [2]. In our own day hospital cohort up to two-thirds of our communitybased falls referrals would have some degree of cognitive impairment. The screening tool used did not take this into consideration and may have contributed to the large drop-out rate and subsequent negative analysis of the falls prevention programme. Also in the subsequent analysis of the paper the authors did not stipulate whether they felt this had played a role in the negative outcome of the paper. The concern is that in a time of fiscal constraints—particularly in a European context—these papers lend weight to a lack of provision for falls prevention in older people. As geriatricians we must aim to emphasise the heterogenous nature of older patients attending our clinics. Differentiating between cognitively impaired and cognitively intact patients may help better inform the design of falls prevention strategies, and which particular patient groups to target.