Practices, issues and possibilities at the interface between geriatrics and palliative care (InGaP): An exploratory study and knotworking

Introduction With the recognition of the need for palliative care for people with non-malignant conditions, there is an increasing emphasis on interdisciplinary working between geriatric and palliative care teams. This interdisciplinary work has evolved organically; more needs to be known about current working practices. This is of policy and clinical interest as the older patient population continues to grow. Methods An exploratory qualitative interview study was undertaken of end-of-life care for older in-patients in a large London NHS Trust. 30 semi-structured qualitative interviews were conducted with staff from palliative care and geriatric medical and nursing teams, two with patients and five with carers. Questions covered: examples and perceptions of collaboration and patient/carer perceptions of clarity as to who was providing care. Interviews were transcribed and thematically analysed focusing on: examples of successful collaboration; areas of tension, duplication or confusion about responsibilities; and suggestions for future practice. Results Participants were positive about collaboration. Examples of what works well include: the referral process to the palliative care team; inter-team communication and use of face-to-face handovers; unity between the teams when communicating with patients and families. Areas for potential development include: embedding palliative care within ward multidisciplinary team meetings; continual on-ward education given rotation of staff; and improving collaboration between palliative care, physiotherapy and occupational therapy. It is unclear whether patients’ and carers’ lack of awareness of the different teams has a detrimental effect on their care or needs. Conclusions There is evidence of strong collaborative working between the teams; however, this study highlights potential areas for improvement. An exploration of these relationships in other settings is required to determine if the same themes arise with a view to inform national guidelines and policy to improve care towards the end of life

Multiple novel prostate cancer susceptibility signals identified by fine-mapping of known risk loci among Europeans

Genome-wide association studies (GWAS) have identified numerous common prostate cancer (PrCa) susceptibility loci. We have fine-mapped 64 GWAS regions known at the conclusion of the iCOGS study using large-scale genotyping and imputation in 25 723 PrCa cases and 26 274 controls of European ancestry. We detected evidence for multiple independent signals at 16 regions, 12 of which contained additional newly identified significant associations. A single signal comprising a spectrum of correlated variation was observed at 39 regions; 35 of which are now described by a novel more significantly associated lead SNP, while the originally reported variant remained as the lead SNP only in 4 regions. We also confirmed two association signals in Europeans that had been previously reported only in East-Asian GWAS. Based on statistical evidence and linkage disequilibrium (LD) structure, we have curated and narrowed down the list of the most likely candidate causal variants for each region. Functional annotation using data from ENCODE filtered for PrCa cell lines and eQTL analysis demonstrated significant enrichment for overlap with bio-features within this set. By incorporating the novel risk variants identified here alongside the refined data for existing association signals, we estimate that these loci now explain ∼38.9% of the familial relative risk of PrCa, an 8.9% improvement over the previously reported GWAS tag SNPs. This suggests that a significant fraction of the heritability of PrCa may have been hidden during the discovery phase of GWAS, in particular due to the presence of multiple independent signals within the same regio

Increasing frailty is associated with higher prevalence and reduced recognition of delirium in older hospitalised inpatients: results of a multi-centre study

Purpose: Delirium is a neuropsychiatric disorder delineated by an acute change in cognition, attention, and consciousness. It is common, particularly in older adults, but poorly recognised. Frailty is the accumulation of deficits conferring an increased risk of adverse outcomes. We set out to determine how severity of frailty, as measured using the CFS, affected delirium rates, and recognition in hospitalised older people in the United Kingdom. Methods: Adults over 65 years were included in an observational multi-centre audit across UK hospitals, two prospective rounds, and one retrospective note review. Clinical Frailty Scale (CFS), delirium status, and 30-day outcomes were recorded. Results: The overall prevalence of delirium was 16.3% (483). Patients with delirium were more frail than patients without delirium (median CFS 6 vs 4). The risk of delirium was greater with increasing frailty [OR 2.9 (1.8–4.6) in CFS 4 vs 1–3; OR 12.4 (6.2–24.5) in CFS 8 vs 1–3]. Higher CFS was associated with reduced recognition of delirium (OR of 0.7 (0.3–1.9) in CFS 4 compared to 0.2 (0.1–0.7) in CFS 8). These risks were both independent of age and dementia. Conclusion: We have demonstrated an incremental increase in risk of delirium with increasing frailty. This has important clinical implications, suggesting that frailty may provide a more nuanced measure of vulnerability to delirium and poor outcomes. However, the most frail patients are least likely to have their delirium diagnosed and there is a significant lack of research into the underlying pathophysiology of both of these common geriatric syndromes