East Midlands Research into Ageing Network (EMRAN) Discussion Paper Series

Academic geriatric medicine in Leicester . There has never been a better time to consider joining us. We have recently appointed a Professor in Geriatric Medicine, alongside Tom Robinson in stroke and Victoria Haunton, who has just joined as a Senior Lecturer in Geriatric Medicine. We have fantastic opportunities to support students in their academic pursuits through a well-established intercalated BSc programme, and routes on through such as ACF posts, and a successful track-record in delivering higher degrees leading to ACL post. We collaborate strongly with Health Sciences, including academic primary care. See below for more detail on our existing academic set-up. Leicester Academy for the Study of Ageing We are also collaborating on a grander scale, through a joint academic venture focusing on ageing, the ‘Leicester Academy for the Study of Ageing’ (LASA), which involves the local health service providers (acute and community), De Montfort University; University of Leicester; Leicester City Council; Leicestershire County Council and Leicester Age UK. Professors Jayne Brown and Simon Conroy jointly Chair LASA and have recently been joined by two further Chairs, Professors Kay de Vries and Bertha Ochieng. Karen Harrison Dening has also recently been appointed an Honorary Chair. LASA aims to improve outcomes for older people and those that care for them that takes a person-centred, whole system perspective. Our research will take a global perspective, but will seek to maximise benefits for the people of Leicester, Leicestershire and Rutland, including building capacity. We are undertaking applied, translational, interdisciplinary research, focused on older people, which will deliver research outcomes that address domains from: physical/medical; functional ability, cognitive/psychological; social or environmental factors. LASA also seeks to support commissioners and providers alike for advice on how to improve care for older people, whether by research, education or service delivery. Examples of recent research projects include: ‘Local History Café’ project specifically undertaking an evaluation on loneliness and social isolation; ‘Better Visits’ project focused on improving visiting for family members of people with dementia resident in care homes; and a study on health issues for older LGBT people in Leicester. Clinical Geriatric Medicine in Leicester We have developed a service which recognises the complexity of managing frail older people at the interface (acute care, emergency care and links with community services). There are presently 17 consultant geriatricians supported by existing multidisciplinary teams, including the largest complement of Advance Nurse Practitioners in the country. Together we deliver Comprehensive Geriatric Assessment to frail older people with urgent care needs in acute and community settings. The acute and emergency frailty units – Leicester Royal Infirmary This development aims at delivering Comprehensive Geriatric Assessment to frail older people in the acute setting. Patients are screened for frailty in the Emergency Department and then undergo a multidisciplinary assessment including a consultant geriatrician, before being triaged to the most appropriate setting. This might include admission to in-patient care in the acute or community setting, intermediate care (residential or home based), or occasionally other specialist care (e.g. cardiorespiratory). Our new emergency department is the county’s first frail friendly build and includes fantastic facilities aimed at promoting early recovering and reducing the risk of hospital associated harms. There is also a daily liaison service jointly run with the psychogeriatricians (FOPAL); we have been examining geriatric outreach to oncology and surgery as part of an NIHR funded study. We are home to the Acute Frailty Network, and those interested in service developments at the national scale would be welcome to get involved. Orthogeriatrics There are now dedicated hip fracture wards and joint care with anaesthetists, orthopaedic surgeons and geriatricians. There are also consultants in metabolic bone disease that run clinics. Community work Community work will consist of reviewing patients in clinic who have been triaged to return to the community setting following an acute assessment described above. Additionally, primary care colleagues refer to outpatients for sub-acute reviews. You will work closely with local GPs with support from consultants to deliver post-acute, subacute, intermediate and rehabilitation care services. Stroke Medicine 24/7 thrombolysis and TIA services. The latter is considered one of the best in the UK and along with the high standard of vascular surgery locally means one of the best performances regarding carotid intervention

UWOMJ Volume 84, Number 1, Spring 2015

Schulich School of Medicine & Dentistryhttps://ir.lib.uwo.ca/uwomj/1246/thumbnail.jp

Guideline-recommended care processes in acute stroke

Introduction: Although clinical guidelines recommend various care processes to improve outcomes of patients with stroke, evidence to support many of them, such as the management of post-stroke infections and the monitoring of abnormal physiological variables, are scarce. While for those care processes with more evidence, very few studies have quantified their variations across regions and what factors influence their implementation in clinical practice. This thesis aims to determine the utilisation of guideline-recommended care processes for patients with acute stroke, and explore various strategies that may improve their implementation. Methods: I conducted secondary analyses of a large clinical trial to explore the associations of care processes and clinical outcomes, using data of 11,093 patients with acute stroke from nine countries. These care processes included dysphagia screening, indwelling urinary catheterisation (IUC), and early detection of low blood pressure (BP) and oxygen saturation (SaO2) levels. To explore variations in the utilisation of care processes, I compared the evidence-based recommendations for stroke unit care across Australia/UK, China, India/Sri Lanka and South America. I also conducted a process evaluation of a ‘quality improvement’ intervention within an ongoing trial involving the management of patients with acute intracerebral haemorrhage in China, to explore what factors could improve the implementation of systems to improve the quality of care. Results: Patients who failed a dysphagia screen, had an IUC, had SBP <120mmHg or SaO2 <93% during the acute phase (up to 7 days after stroke onset) had increased odds of poor outcome. The utilisation of care processes varied across regions, with lower probabilities of reperfusion therapy and allied health care in low- and middle-income countries (LMICs) than high-income countries. Constant training with the clinicians, case reviews, optimisation of workflow within available resources, and having a dedicated team, may facilitate the implementation of evidence-based care. Conclusions: The utilisations of guideline-recommended care processes are associated with patient outcomes and vary across regions. Timely assessment and appropriate management should be provided to those with dysphagia, IUC, low BP, and low SaO2 levels, in an effort to improve their recovery after stroke. Future studies are needed to confirm the causality of these associations and to examine opportunities to promote the delivery of evidence-based stroke care, especially in LMICs

Brain hypothermia in ischemic stroke: non-invasive thermometry and molecular basis

Ischemic stroke is a leading cause of death and morbidity around the world. However, only one pharmacological treatment is currently available, the tissue plasminogen activator or rtPA. Preclinical studies demonstrated the high therapeutic potential of hypothermia to mitigate the effects of stroke, but this therapy has not been successfully translated to the clinics due to the side effects associated to cold (shivering, arrhythmia, or pneumonia among others), and due to the lack of non-invasive methods to assess brain temperature. The present work provides new data about the therapeutic potential of focal brain hypothermia as alternative to systemic cooling, the use of non-invasive magnetic resonance thermometry to measure brain temperature, and the possible implication of RBM3, a cold shock protein, in the molecular process underlying the protective effect of cold

Added value of acute multimodal CT-based imaging (MCTI) : a comprehensive analysis

Introduction: MCTI is used to assess acute ischemic stroke (AIS) patients.We postulated that use of MCTI improves patient outcome regardingindependence and mortality.Methods: From the ASTRAL registry, all patients with an AIS and a non-contrast-CT (NCCT), angio-CT (CTA) or perfusion-CT (CTP) within24 h from onset were included. Demographic, clinical, biological, radio-logical, and follow-up caracteristics were collected. Significant predictorsof MCTI use were fitted in a multivariate analysis. Patients undergoingCTA or CTA&amp;CTP were compared with NCCT patients with regards tofavourable outcome (mRS ≤ 2) at 3 months, 12 months mortality, strokemechanism, short-term renal function, use of ancillary diagnostic tests,duration of hospitalization and 12 months stroke recurrence

Diagnosing and Managing Post-Stroke Aphasia

Introduction: Aphasia is a debilitating language disorder and even mild forms of aphasia can negatively affect functional outcomes, mood, quality of life, social participation, and the ability to return to work. Language deficits after post-stroke aphasia are heterogeneous. Areas covered: The first part of this manuscript reviews the traditional syndrome-based classification approach as well as recent advances in aphasia classification that incorporate automatic speech recognition for aphasia classification. The second part of this manuscript reviews the behavioral approaches to aphasia treatment and recent advances such as noninvasive brain stimulation techniques and pharmacotherapy options to augment the effectiveness of behavioral therapy. Expert opinion: Aphasia diagnosis has largely evolved beyond the traditional approach of classifying patients into specific syndromes and instead focuses on individualized patient profiles. In the future, there is a great need for more large scale randomized, double-blind, placebo-controlled clinical trials of behavioral treatments, noninvasive brain stimulation, and medications to boost aphasia recovery