Rebekah Schiff

Advanced care planning in care homes for older people: a qualitative study of the views of care staff and families

OBJECTIVE to explore views on advance care planning in care homes for older people. DESIGN qualitative exploration of views from care home staff and the family of residents in care homes for older people. SETTING all care homes for the elderly in two London Boroughs. PARTICIPANTS staff (care managers, nurses and care assistants), community nurses and families. METHODS individual semi-structured interviews. RESULTS themes of the analysis: (i) BENEFITS staff and family revealed positive opinions towards advance care planning. Staff felt it provided choice for residents and encouraged better planning. (ii) Barriers: staff and families perceived residents as reluctant to discuss advance care planning. Some care assistants were reluctant to be involved. Furthermore, families and staff reported prevalence of dementia among residents as another barrier. Nurses and care managers identified both family involvement and unforeseen medical circumstances as problematic. (iii) Facilitators: (a) early initiation of discussions (b) family involvement to establish preferences (c) residents and staff being well-known to each other and (d) staff training, were perceived to facilitate ACP. CONCLUSIONS overall, staff and families support the concept of ACP. Methods to overcome the identified barriers are required to embed ACP within end of life care in care homes.

Short-term transdermal estradiol therapy, cognition and depressive symptoms in healthy older women. A randomised placebo controlled pilot cross-over study

The potential role of estrogen in protecting women from cognitive decline and reducing depressive symptoms is of great therapeutic interest. In a pilot randomised placebo controlled cross-over study, we aimed to determine the short-term effects of transdermal estradiol therapy on cognition and depressive symptoms in healthy cognitively normal post-menopausal women over 60 years of age. Nineteen cognitively normal women, without clinical depression whom had undergone a hysterectomy in the past were recruited. Women were randomised to receive either transdermal estradiol 50 microg/24 h (Femseven) or transdermal placebo for 12 weeks before crossing over to the other medication for a further 12 weeks. Cognition was assessed every 6 weeks by the cognitive drug research (CDR) computerised assessment which recorded both accuracy and speed in the following cognitive tests; simple reaction time, choice reaction time, digit vigilance, visual tracking, spatial working memory, immediate and delayed word recall and delayed face and picture recall. Depressive symptoms were measured using the brief assessment scale depression card (BASDEC) depression rating scale at baseline, 12 and 24 weeks. Participants had a mean age of 71, IQ of 115 and MMSE of 29. Simple reaction time and the BASDEC depression rating scale improved after 12 weeks of estradiol use. All other tests were unaltered by estradiol. Twelve weeks of transdermal estradiol therapy did not consistently improve the speed or accuracy of older women in various cognitive tests. However, the results do support the concept that depressive symptoms may be reduced by estradiol, and not simply due to the relief of climacteric symptoms.

Simulation training for improving the quality of care for older people: an independent evaluation of an innovative programme for inter-professional education

Introduction This paper describes the evaluation of a 2-day simulation training programme for staff designed to improve teamwork and inpatient care and compassion in an older persons’ unit. Objective The programme was designed to improve inpatient care for older people by using mixed modality simulation exercises to enhance teamwork and empathetic and compassionate care. Methods Healthcare professionals took part in: (a) a 1-day human patient simulation course with six scenarios and (b) a 1-day ward-based simulation course involving five 1-h exercises with integrated debriefing. A mixed methods evaluation included observations of the programme, precourse and postcourse confidence rating scales and follow-up interviews with staff at 7–9 weeks post-training. Results Observations showed enjoyment of the course but some anxiety and apprehension about the simulation environment. Staff self-confidence improved after human patient simulation (t=9; df=56; p<0.001) and ward-based exercises (t=9.3; df=76; p<0.001). Thematic analysis of interview data showed learning in teamwork and patient care. Participants thought that simulation had been beneficial for team practices such as calling for help and verbalising concerns and for improved interaction with patients. Areas to address in future include widening participation across multi-disciplinary teams, enhancing post-training support and exploring further which aspects of the programme enhance compassion and care of older persons. Conclusions The study demonstrated that simulation is an effective method for encouraging dignified care and compassion for older persons by teaching team skills and empathetic and sensitive communication with patients and relatives.

Irbesartan improves arterial compliance more than lisinopril

Background Antihypertensive agents can reduce arterial stiffness. We hypothesized that an angiotensin receptor blocker (ARB) irbesartan and an angiotensin converting enzyme inhibitor (ACEI) lisinopril improved arterial compliance. Methods A randomized, double-blind, double-dummy, controlled crossover trial. Fifteen hypertensive patients, mean age 65.5 ± 8.9 years (mean ± SD) were given irbesartan (150 to 300 mg/day) or lisinopril (10 to 20 mg/day) for 12 weeks and then crossed over for 12 weeks. Pulse wave velocity (PWV) in the carotid-femoral (CF), carotid-radial (CR), and femoral dorsalis-pedis (FD) were measured using a Complior® PWV system. Results After 12 weeks, systolic blood pressure (SBP) decreased from 162.4 ± 12.9 to 134.5 ± 14.8 with irbesartan and to 145.2 ± 25 mmHg with lisinopril. Irbesartan and lisinopril reduced PWV (CF) in the elastic arterial system from 15.1 ± 5 to 13.3 ± 2.6 (p < 0.005) and to 14 ± 4.7 (p < 0.05) m/s respectively (p = 0.345). Irbesartan reduced PWV (CR) and PWV (FD), whereas lisinopril did not. The difference between treatments was significant after SBP adjustment (p = 0.037 for PWV (CR) and p < 0.001 for PWV (FD)). Conclusions Irbesartan improved arterial compliance in elastic and muscular arteries, whereas lisinopril improved it only in elastic arteries.

A short case prolonged

As a senior house officer who had worked only at district general hospitals, I made my first attempt at the MRCP clinical examination at a prestigious London teaching hospital in a state of nervous dread. The “short cases”—when you are taken by two examiners and a nurse to a succession of patients—are seen as the most challenging part of the exam. Half way through my short cases, I was taken to see a frail elderly man and asked to examine his …

Incidence and cost of medication harm in older adults following hospital discharge: a multicentre prospective study in the UK

Polypharmacy is increasingly common in older adults, placing them at risk of medication‐related harm (MRH). Patients are particularly vulnerable to problems with their medications in the period following hospital discharge due to medication changes and poor information transfer between hospital and primary care. The aim of the present study was to investigate the incidence, severity, preventability and cost of MRH in older adults in England postdischarge.

Can doctors identify older patients at risk of medication harm following hospital discharge? A multicentre prospective study in the UK

Medication‐related harm (MRH) is common in older adults following hospital discharge. In resource‐limited health systems, interventions to reduce this risk can be targeted at high‐risk patients. This study aims to determine whether (1) doctors can predict which older patients will experience MRH requiring healthcare following hospital discharge, (2) clinical experience and confidence in prediction influence the accuracy of the prediction.

Evidence and tips on the use of medication compliance aids

### What you need to know Older people, and those with frailty and multiple comorbidities can have complex medication regimens, which can be challenging for patients, carers, and healthcare practitioners to manage. Some patients choose not to take all their medications (intentional non-adherence)—this accounts for approximately 50% of non-adherence in patients over the age of 65.123 Others, for example those with cognitive impairment, may forget or find it difficult to manage taking their medication (unintentional non-adherence). To address unintentional non-adherence, patients can use electronic reminders and devices, support from carers, and medication compliance aids (MCAs) to help them follow their medication regimens.4 Use of multi-compartment MCAs seems to be increasing, although there are no reliable data on UK prevalence.5 Multi-compartment MCAs can be called multi-dose drug dispensing systems, or “Dossett Boxes” after one of the original marketed versions.567 Examples or other brands include NOMAD and Venalink. Importantly, these devices only store …

Comparison of the Diagnostic Accuracy of Plasma N-Terminal Pro-Brain Natriuretic Peptide in Patients 80 Years of Age with Heart Failure

Plasma N-Terminal Pro-Brain Natriuretic Peptide (NTproBNP) is known to increase with age, however, the performance of this biomaker is unclear in patients >80. This study sought to define the diagnostic accuracy of plasma NTproBNP in patients >80 in a large unselected population of heart failure (HF) patients admitted to a Tertiary Hospital in the United Kingdom. 1,995 consecutive patients over a 12 month period were screened for HF through our NTproBNP led HF service. 413 patients had their first presentation of HF and 36.1% of these patients were >80. There was a reduction in accuracy of NTproBNP with age according to the area under the curve, with an area under the curve for all HF patients of 0.734 and a 7.5% reduction in receiver operating characteristic curve area for patients >80 years compared with those under 60 to 79 years of age. The lowest NTproBNP recorded for patients with HF >80 years of age was 466 pg/ml. In HF patients >80, 40.6% patients were diagnosed with HFrEF, 31.1% with HFpEF and 28.2% with HFmrEF. Overall NTproBNP is less accurate at identifying HF in patients >80 years of age and the lowest NTproBNP recorded for a HF patient was 466 pg/ml suggesting that the NTproBNP threshold for ruling out HF in patients >80 years of age should be modified.