The nutritional needs of people living with COPD: a concurrent mixed methods study of the role of the general practice nurse

Chronic Obstructive Pulmonary Disease (COPD) affects an estimated 1.2 million people across England, equating to 2% of the overall population. The respiratory disease can be diagnosed and managed in the community, the audit of which is one of the key quality indicators for General Practice. It is within this setting that general practice nurses have a key role in caring for people living with the disease. This study aimed to examine the role of the general practice nurse in the diagnosis and management of nutritional care of people living with COPD. The study was guided by a pragmatic philosophical approach resulting in a mixed methods design to examine the role of the general practice nurse in the nutritional care of people living with COPD across Greater Manchester, UK. The quantitative phase utilised a questionnaire, to survey 201 general practices in phase one across Greater Manchester, which led to phase two of the research, where eight qualitative unstructured interviews across seven of the ten boroughs of Greater Manchester. Phase one of the quantitative data was analysed using SPSS Version 19. The qualitative data were analysed using the framework of thematic analysis as presented by Braun and Clarke (2006). The survey of general practice nurses (GPNs) demonstrated that whilst there were similarities across general practices in Greater Manchester with COPD care (in line with the quality outcomes framework QOF), there was diverse practice relating to nutritional care of the same group of patients. GPNs predominately perceived their practice, in the care of those living with COPD to align with an advanced or intermediate way (in line with the model by Upton et al, 2007). The qualitative interviews provided some context to practice with seven main themes emerging from the data including: biomedical task orientated care; financial drivers; time and resources; nutrition and COPD; confidence and diabetes care; inter-professional/nurse-to-nurse relationships and education; training; and role vulnerability. It was evident that the quality outcomes framework (QOF) influenced nursing practice across many of the themes identified in the analysis. This is the first study to examine the role of the GPN in the nutritional care of people living with COPD in the community, and to discuss the impact of the QOF on the delivery of care. The care of people living with COPD in the community is largely undertaken by general practice nurses. Practice nurses provide care in accordance with the Quality Outcomes Framework (2004), that financially rewards practices for compliance, but is seen to inhibit holistic COPD care. Many participants lacked confidence when providing nutritional care for people living with COPD, which resulted in an assumption that such care should be aligned with another service or professional. A model to connect the person with their nurse, GP, dietitian and rehabilitation services could enhance a holistic and more rounded approach for COPD care, which incorporates nutritional practice as part of a whole person’s treatment plan

Deprescribing tool for STOPPFall (screening tool of older persons prescriptions in older adults with high fall risk) items

Background: Health care professionals are often reluctant to deprescribe fall-risk-increasing drugs (FRIDs). Lack of knowledge and skills form a significant barrier. To support clinicians in the management of FRIDs and to facilitate the deprescribing process, a deprescribing tool was developed by a European expert group for STOPPFall (Screening Tool of Older Persons Prescriptions in older adults with high fall risk) items. Methods: STOPPFall was created using an expert Delphi consensus process in 2019 and in 2020, 24 panellists from EuGMS SIG on Pharmacology and Task and Finish on FRIDs completed deprescribing tool questionnaire. To develop the questionnaire, a Medline literature search was performed. The panellists were asked to indicate for every medication class a possible need for stepwise withdrawal and strategy for withdrawal. They were asked in which situations withdrawal should be performed. Furthermore, panellists were requested to indicate those symptoms patients should be monitored for after deprescribing and a possible need for follow-ups. Results: Practical deprescribing guidance was developed for STOPPFall medication classes. For each medication class, a decision tree algorithm was developed including steps from medication review to symptom monitoring after medication withdrawal. Conclusion: STOPPFall was combined with a practical deprescribing tool designed to optimize medication review. This practical guide can help overcome current reluctance towards deprescribing in clinical practice by providing an up-to-date and straightforward source of expert knowledge

Physical activity and exercise in dementia : an umbrella review of intervention and observational studies

Background: Dementia is a common condition in older people. Among the potential risk factors, increasing attention has been focused on sedentary behaviour. However, synthesizing literature exploring whether physical activity/exercise can affect health outcomes in people with dementia or with mild cognitive impairment (MCI) is still limited. Therefore, the aim of this umbrella review, promoted by the European Geriatric Medicine Society (EuGMS), is to understand the importance of physical activity/exercise for improving cognitive and non-cognitive outcomes in people with dementia/MCI. Methods: Umbrella review of systematic reviews (SR) (with or without meta-analyses) of randomized controlled trials (RCTs) and observational (prospective and case-control in people with MCI) studies based on a systematic literature search in several databases. The certainty of evidence of statistically significant outcomes attributable to physical activity/exercise interventions was evaluated using Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Results: Among 1,160 articles initially evaluated, 27 systematic reviews (4 without meta-analysis) for a total of 28,205 participants with dementia/MCI were included. No observational study on physical activity/exercise in MCI for preventing dementia was included. In SRs with MAs, physical activity/exercise was effective in improving global cognition in Alzheimer’s disease and in all types of dementia (very low/low certainty of evidence). Moreover, physical activity/ exercise significantly improved global cognition, attention, executive function, and memory in MCI, with a certainty of evidence varying from low to moderate. Finally, physical activity/exercise improved non-cognitive outcomes in people with dementia including falls and neuropsychiatric symptoms. SRs, without meta-analysis, corroborated these results. Conclusions: Supported by very low to moderate certainty of evidence, physical activity/exercise has a positive effect on several cognitive and non-cognitive outcomes in people with dementia and MCI, but RCTs, with low risk of bias/confounding, are still needed to confirm these findings

Association between number of medications and mortality in geriatric inpatients : a Danish nationwide register-based cohort study

Purpose: To explore the association between the number of medications and mortality in geriatric inpatients taking activities of daily living and comorbidities into account. Methods: A nationwide population-based cohort study was performed including all patients aged C65 years admitted to geriatric departments in Denmark during 2005-2014. The outcome of interest was mortality. Activities of daily living using Barthel-Index (BI) were measured at admission. National health registers were used to link data on an individual level extracting data on medications, and hospital diseases. Patients were followed to the end of study (31.12.2015), death, or emigration, which ever occurred first. Kaplan-Meier survival curves were used to estimate crude survival proportions. Univariable and multivariable analyses were performed using Cox regression. The multivariable analysis adjusted for age, marital status, period of hospital admission, BMI, and BI (model 1), and further adding either number of diseases (model 2) or Charlson comorbidity index (model 3). Results: We included 74603 patients (62.8% women), with a median age of 83 (interquartile range [IQR] 77-88) years. Patients used a median of 6 (IQR 4-9) medications. Increasing number of medications was associated with increased overall, 30-days, and 1-year mortality in all 3 multivariable models for both men and women. For each extra medication the mortality increased by 3% in women and 4% in men in the fully adjusted model. Conclusion: Increasing number of medications was associated with mortality in this nationwide cohort of geriatric inpatients. Our findings highlight the importance of polypharmacy in older patients with comorbidities

AN EVALUATION OF THE NORTHAMPTON PHYSICAL HEALTH AND WELLBEING (PhyHWell) PROJECT

Abstract Background The first study to demonstrate that life expectancy in patients with a severe mental illness (SMI) was reduced was by Farr in 1841. More recently, comparative research has demonstrated a higher level of cardiovascular disease (CVD) than the rest of the population in this group. Despite this knowledge, little has changed in routine practice. One barrier could be that the educational needs of the primary care healthcare professionals in this area are not being met. Aims The aim of this programme of research is to address the physical health needs of people with SMI by improving the practice of healthcare professionals in primary care. Methods The methods employed are the development of a training package and a programme of research divided into eight studies: 1. A retrospective audit to find out whether patients will attend for a health check if they are invited. 2. A prospective audit to see if a tool used for people with physical illnesses to improve their lifestyle (a food diary) is as effective when used with the SMI population. 3. A systematic search to find out what evidence there is for the efficacy of healthcare professional educational outcomes in studies of physical health in SMI. 5 4. The development of a training package for practice nurses to teach them how to carry out physical health checks for people with SMI. 5. A retrospective audit to establish whether as many people with SMI are being screened for cardiovascular disease as people with physical conditions in Northampton. 6. An audit to find out whether as many people with SMI are being screened for cardiovascular disease as people with physical conditions in England. 7. A before and after study to measure the effect of a physical health and SMI training on the practice nurses’ motivation to carry out physical health checks for people with SMI. 8. A before and after study to establish whether training practice nurses to carry out physical health checks for people with SMI increases the level of screening for cardiovascular risk in this group. 9. A qualitative study using interviews with patients with SMI to find out what they think about the physical health checks. Results There were a total of 2,796 patients and eight healthcare professionals included in the programme in Northampton and 2,911,914 patients in the national study. People with SMI will attend for a health check if invited by letter giving them an appointment with a named practitioner (66%). The patients with schizophrenia were all successful in completing food diaries. There were no studies identified as suitable for a systematic review. In the five participating primary care practices in Northampton, the people with SMI received less CVD screening than those with diabetes (21% v 96%, CI=64.53 to 126.55: p<.01). In the 6 national study, patients with diabetes received higher levels of screening in the previous 15 months than those with SMI (97.3% vs 74.7%; p<0.0001). The attitudes of the practice nurses involved in the study towards their role in providing health checks appeared to be modified in a positive direction. Following the training of practice nurses, each individual patient received more CVD screening and lifestyle information (3.85 v 2.69: t=8.22, p<.05). The patients who were interviewed about their physical health check had a good understanding of the importance of a healthy diet and taking regular exercise but did not appear aware of the risk of cardiovascular disease. Conclusion Simple changes in the way patients with SMI are invited to attend a health check increases attendance rates. The quality of primary care health checks for this population is inferior to those provided to patients with diabetes. Training practice nurses improves the quality of the health checks but still not to the levels received by other patient groups

Living with a long-term condition: a grounded theory.

This study explores and explains how people make sense of their long-term, potentially life-threatening, health condition. Thrombophilia offers an example of a little-researched condition which may not affect people significantly on a day-to-day basis, but can lead to acute illness. The second condition under consideration, asthma, was selected due to its similarity in this regard. The literature indicates that information about long-term conditions is acquired from various sources and influenced by experience. Such conditions are frequently perceived as being problematic. However, some are accepted, and affected individuals can achieve wellbeing. The literature does not offer insights into how knowledge may support this process of achieving wellbeing. A constructivist grounded theory approach was adopted, and interviews used to collect data from ten individuals affected by thrombophilia. Constant comparison of the data was carried out. Theoretical sampling suggested the inclusion of six people with a second long-term condition, and the process continued until saturation was reached. Findings indicated a two stage process. Gaining knowledge comprises of phases occurring pre-diagnosis and during diagnosis, and this assists participants in making sense of their condition. Living with a long-term condition consists of the phases making informed decisions, accepting the condition, and living with it. Previous research has not elucidated this entire process or the importance of the pre-diagnosis phase. Based on these findings, a theory is offered. This proposes that individuals diagnosed with a long-term condition create constructs about it based on information and experiences, which are used as the foundation for decisionmaking. Some people are able to accept their condition and its nuances. Those who understand their condition, make informed decisions and accept it are able to live with it. Those who are unable to do so will live alongside their condition and do not integrate it into their lives